Increased Health Resource Utilization Research Articles

P.116 Days at home after traumatic brain injury: moving beyond mortality to evaluate patient-centered outcomes using population health data

Background: Despite the utility of administrative health data, there remains a lack of patient-centered outcome measures to meaningfully capture morbidity after traumatic brain injury (TBI). We sought to characterize and validate days at home (DAH) as a feasible measure to assess population-level moderate to severe TBI (msTBI) outcomes and health resource utilization. Methods: We utilized linked health administrative data sources to identify adults with msTBI patients presenting to trauma centers in Ontario injured between 2009-2021. DAH at 180 days reflects the total number of days spent alive and at home excluding the days spent institutionalized in acute care, rehabilitation, inpatient mental health settings or post-acute readmissions. Construct and predictive validity were determined; we additionally estimated minimally important difference (MID) in DAH180days. Results: There were 6340 patients that met inclusion criteria. Median DAH180days were 70 days (interquartile range 0-144). Increased health resource utilization at baseline, older age, increasing cranial injury severity and major extracranial injuries were significantly associated with fewer DAH180days. DAH180days was correlated to DAH counts at 1-3 years. The average MID estimate from anchor-based and distribution-based methods was 18 days. Conclusions: We introduce DAH180days as a feasible and sufficiently responsive patient-centered outcome measure with construct, predictive and face validity in an msTBI population.

Cost-effectiveness of sutimlimab in cold agglutinin disease.

Primary cold agglutinin disease (CAD) is a rare autoimmune hemolytic anemia caused by cold-reactive antibodies that bind to red blood cells and lead to complement-mediated hemolysis. Patients with primary CAD experience the burden of increased health resource utilization and reduced quality of life. The standard-of-care (SOC) in patients with primary CAD has included cold avoidance, transfusion support, and chemoimmunotherapy. The use of sutimlimab, a humanized monoclonal antibody that selectively inhibits C1-mediated hemolysis, was shown to reduce transfusion-dependence and improve quality of life across two pivotal phase 3 studies, further supported by 2-year extension data. Using data from the transfusion-dependent patient population that led to sutimlimab's initial FDA approval, we performed the first-ever cost-effectiveness analysis in primary CAD. The projected incremental cost-effectiveness ratio (ICER) in our Markov model was $2 340 000/QALY, significantly above an upper-end conventional US willingness-to-pay threshold of $150 000/QALY. These results are consistent across scenarios of higher body weight and a pan-refractory SOC patient phenotype (i.e., treated sequentially with bendamustine-rituximab, bortezomib, ibrutinib, and eculizumab). No parameter variations in deterministic sensitivity analyses changed our conclusion. In probabilistic sensitivity analysis, SOC was favored over sutimlimab in 100% of 10 000 iterations. Exploratory threshold analyses showed that significant price reduction (>80%) or time-limited treatment (<18 months) followed by lifelong clinical remission off sutimlimab would allow sutimlimab to become cost-effective. The impact of sutimlimab on health system costs with longer term follow-up data merits future study and consideration through a distributional cost-effectiveness framework.

Does the introduction of an infliximab biosimilar always result in savings for hospitals? A descriptive study using real-world data

BackgroundBiosimilars are biologic drugs that have the potential to increase the efficiency of healthcare spending and curb drug-related cost increases. However, their introduction into hospital formularies through initiatives such as non-medical switching must be carefully orchestrated so as not to cause treatment discontinuation or result in increased health resource utilization, such as additional visits or laboratory tests, among others. This retrospective cohort study aims to assess the impact of the introduction of CT-P13 on the healthcare expenditures of patients who were treated with originator infliximab or CT-P13.MethodsGastroenterology, immunoallergology and rheumatology patients treated between September 2017 and December 2020 at a university hospital in Western Switzerland were included and divided into seven cohorts, based on their treatment pathway (i.e., use and discontinuation of CT-P13 and/or originator infliximab). Costs in Swiss francs were obtained from the hospital's cost accounting department and length of stay was extracted from inpatient records. Comparisons of costs and length of stay between cohorts were calculated by bootstrapping.ResultsSixty immunoallergology, 84 rheumatology and 114 gastroenterology patients were included. Inpatient and outpatient costs averaged (sd) CHF 1,611 (1,020) per hospital day and CHF 4,991 (6,931) per infusion, respectively. The mean (sd) length of stay was 20 (28) days. Although immunoallergology and rheumatology patients had higher average costs than gastroenterology patients, differences in costs and length of stay were not formally explained by treatment pathway. Differences in health resource utilization were marginal.ConclusionsThe introduction of CT-P13 and the disruption of patient treatment management were not associated with differences in average outpatient and inpatient costs and length of stay, in contrast to the results reported in the rest of the literature. Future research should focus on the cost-effectiveness of non-medical switching policies and the potential benefits for patients.

The Effects of Peri-Operative Adverse Events on Clinical and Patient-Reported Outcomes After Surgery for Degenerative Cervical Myelopathy: An Observational Cohort Study from the Canadian Spine Outcomes and Research Network.

There is a lack of data examining the effects of perioperative adverse events (AEs) on long-term outcomes for patients undergoing surgery for degenerative cervical myelopathy. We aimed to investigate associations between the occurrence of perioperative AEs and coprimary outcomes: (1) modified Japanese Orthopaedic Association (mJOA) score and (2) Neck Disability Index (NDI) score. We analyzed data from 800 patients prospectively enrolled in the Canadian Spine Outcomes and Research Network multicenter observational study. The Spine AEs Severity system was used to collect intraoperative and postoperative AEs. Patients were assessed at up to 2 years after surgery using the NDI and the mJOA scale. We used a linear mixed-effect regression to assess the influence of AEs on longitudinal outcome measures as well as multivariable logistic regression to assess factors associated with meeting minimal clinically important difference (MCID) thresholds at 1 year. There were 167 (20.9%) patients with minor AEs and 36 (4.5%) patients with major AEs. The occurrence of major AEs was associated with an average increase in NDI of 6.8 points (95% CI: 1.1-12.4, P = .019) and reduction of 1.5 points for mJOA scores (95% CI: -2.3 to -0.8, P < .001) up to 2 years after surgery. Occurrence of major AEs reduced the odds of patients achieving MCID targets at 1 year after surgery for mJOA (odds ratio 0.23, 95% CI: 0.086-0.53, P = .001) and for NDI (odds ratio 0.34, 95% CI: 0.11-0.84, P = .032). Major AEs were associated with reduced functional gains and worse recovery trajectories for patients undergoing surgery for degenerative cervical myelopathy. Occurrence of major AEs reduced the probability of achieving mJOA and NDI MCID thresholds at 1 year. Both minor and major AEs significantly increased health resource utilization by reducing the proportion of discharges home and increasing length of stay.

Predictors of Diagnostic Delays and Loss to Follow-up in Women with Von Willebrand Disease

Background: Diagnostic and treatment delays in von Willebrand disease (vWD) disproportionately affect women. Such delays may lead to poor health outcomes from preventable bleeding complications related to menstruation, childbirth, and surgeries. They may also result in increased health resource utilization, including increased emergency department (ED) visits, transfusions, and surgical interventions. Patient and disease-related factors associated with diagnostic delays and loss to follow-up have been poorly documented, but are important to examine particularly in relation to gynecological outcomes. Aims: 1) To examine the prevalence and predictors of diagnostic delays and loss to follow-up in women with vWD. 2) To assess the impact of diagnostic delays on rates of ED visits, red cell transfusions, and hysterectomies. Methods: This retrospective cohort study included women ≥18 years with a diagnosis of vWD followed by the Northern Alberta Bleeding Disorders Program. Diagnostic delay was determined from the time of first documented bleeding event to the time of vWD diagnosis, with delayed diagnosis defined as &amp;gt;5 years. All bleeding events on the ISTH-BAT were included in the above definition, except for easy bruising due to its subjectivity and suboptimal documentation. Loss to follow-up was defined as ≥5 years since last hematology visit at the time of data collection. We collected the following patient and disease-related factors: age, rural status, year of diagnosis (pre-2000, 2000-2010, or 2011-2021), vWD type, baseline vWF activity, ISTH-BAT, family history of vWD, abnormal coagulation screen (INR/aPTT) prior to diagnosis, and status-post endometrial ablation or hysterectomy. Logistic regression was used to assess predictors of diagnostic delays and loss to follow-up. Research ethics approval was obtained. Results: We included 173 women: 140 (81%) type 1, 23 (13%) type 2, 5 (3%) type 3, and 5 (3%) platelet-type vWD. The median age of diagnosis was 27 years (IQR 18-38). The median time from first bleeding symptom to vWD diagnosis was 12.1 years (IQR 4.6-24.2), with 66 (38%) women presenting with ≥3 bleeding events prior to diagnosis. Further, 71 (41%) presented with ≥1 severe bleeding event (requiring ED visit, hospitalization, red cell transfusion, or surgical hemostasis) prior to diagnosis. Timing from first bleeding symptom to diagnosis was available in 154 (89%) women, of whom 113 (73%) experienced delayed diagnosis. Compared to women with delayed diagnosis, those diagnosed within 5 years of their first bleeding symptom were more likely to have a known family history of vWD (51% vs 26%, P=0.01) or have been diagnosed between 2000-2010 (56% vs 33%, P=0.002). Urban/rural residence, vWD type, baseline vWF activity, blood type, and abnormal coagulation screen were not significantly associated with diagnostic delays (Table 1). Of the 155 patients with available follow-up data, 44 (28%) were lost to follow-up for ≥5 years. Only rural residence (OR 1.8, 95% CI 0.9-5.3, P=0.07) trended towards higher odds of loss to follow-up. Age, year of diagnosis, vWD type, baseline vWF activity, ISTH-BAT, and prior hysterectomy/ablation status were not associated with loss to follow-up. Women with diagnostic delays had a significantly higher ISTH-BAT (median 7 vs 5, P=0.005). They also had significantly higher rates of hysterectomies for heavy menstrual bleeding (HMB; 20% vs 0%, P=0.0006), as well as a non-significant trend towards higher rates of dilatation and curettage (D&amp;C; 12% vs 2%, P=0.11) and endometrial ablations (12% vs 5%, P=0.36) (Table 2). 17 women underwent surgical procedures for HMB (D&amp;C, endometrial ablation, and/or hysterectomy) prior to their vWD diagnosis. Conclusion: Women with vWD often experience prolonged diagnostic delays. In our study, many women had bleeding symptoms for at least 5 years, and often greater than 10 years, prior to diagnosis. There was also a high rate of loss to follow-up, particularly in rural populations. Delayed diagnosis occurred even in women with a known family history of vWD and in women with severe bleeding events. Alarmingly, the rate of delayed diagnosis increased over time and was associated with higher rates of surgical interventions for HMB. For this reason, a high index of suspicion is paramount to ensure a prompt diagnosis of vWD, as this may prevent severe gynecological bleeding complications and their need for invasive surgical management.

Cost-Effectiveness of Sutimlimab Versus Standard-of-Care in Transfusion Dependent Patients with Primary Cold Agglutinin Disease in the United States

Introduction: Primary cold agglutinin disease (CAD) is an autoimmune hemolytic anemia characterized by the presence of cold-reactive antibodies that lead to red blood cell destruction at low temperatures. Patients with CAD who are transfusion-dependent experience the burden of increased health resource utilization and reduced quality-of-life. The standard-of-care (SOC) in patients with primary CAD has included chemoimmunotherapy, transfusion support, and cold avoidance. Sutimlimab is a humanized monoclonal antibody that selectively inhibits C1-mediated hemolysis. It is the only FDA-approved therapeutic for patients with cold agglutinin disease regardless of history of transfusion, with approval based on two phase 3 clinical studies. The cost-effectiveness of this expensive therapeutic in the care of patients with either transfusion-independent or transfusion-dependent primary CAD is not known. We sought to fill this gap by determining the cost-effectiveness of sutimlimab versus standard-of-care for the transfusion-dependent patient population with primary CAD. Methods: For this independent analysis free of industry influence, we built a Markov state transition model of adult patients with transfusion-dependent primary CAD to determine the cost-effectiveness of sutimlimab versus SOC, over a lifetime time-horizon and across accepted willingness-to-pay thresholds in US dollars per quality-adjusted life-year (QALY). For transition probabilities, we employed phase 3 study data (NCT03347396) with descriptive statistics informing the documented pre- versus on-sutimlimab clinical benefit, including the decrement in hemolytic anemia severity and transfusion burden. For SOC, we assumed that all patients undergo the costs and risks of chemoimmunotherapy with bendamustine-rituximab, followed by rituximab monotherapy and subsequent treatment with mycophenolate mofetil, with all patients remaining dependent on transfusion care. Health resource utilization costs for SOC were further supplemented with country- and disease-specific real-world costs over a median of 42.8 and 33.0 months of follow-up after incident primary CAD diagnosis across two claims databases. These costs were assessed from the highest of 1) annualized cost quartile and 2) the worst ordinal category of hemolytic anemia severity (defined as hemoglobin &amp;lt;8 g/dL) across all of 1) hospitalizations, 2) emergency visits, 3) outpatient services, and 4) blood transfusions. We assumed no loss of sutimlimab efficacy and no discontinuation off sutimlimab due to adverse events. Age- and sex-adjusted, disease-specific mortality was employed. Effectiveness was calculated in QALYs and was informed directly from trial-specific utilities. The primary outcome was the incremental cost-effectiveness ratio (ICER) or the incremental net monetary benefit (iNMB), if the intervention was found to be cost-saving. The secondary outcome was a scenario analysis for patients with a body weight of &amp;lt;75 kilograms that mandate lower dosing per-kilogram sutimlimab dosing, as per the FDA package insert. We concluded by conducting deterministic and probabilistic sensitivity analyses, capturing uncertainty in all parameters simultaneously over 10,000 Monte Carlo simulations. Results: In the base-case analysis, treatment with sutimlimab versus SOC accrued 5.60 and 4.79 QALYs at costs of $9.52 and $7.67 million, respectively, with the ICER for sutimlimab treatment being $2,280,000/QALY [95% credible interval 960,000-13,900,000]. In the scenario analysis for patients with lower body weight (i.e., lower sutimlimab dosing), the ICER was $1,910,000/QALY. Model results were sensitive to sutimlimab cost. In a probabilistic sensitivity analysis, SOC was favored over sutimlimab in 100% of 10,000 iterations. An exploratory threshold analysis showed that the mortality hazard with sutimlimab would need to decrease by 201% for sutimlimab to become cost-effective. Conclusion: Sutimlimab is conventionally cost-ineffective compared to SOC in transfusion-dependent patients with CAD. Distributional cost-effectiveness analysis (DCEA) to potentially justify sutimlimab as an equitable therapeutic option despite cost-ineffectiveness in the United States context is needed.

Impacts of antipsychotic medication prescribing practices in critically ill adult patients on health resource utilization and new psychoactive medication prescriptions.

Antipsychotic medications are commonly prescribed to critically ill adult patients and initiation of new antipsychotic prescriptions in the intensive care unit (ICU) increases the proportion of patients discharged home on antipsychotics. Critically ill adult patients are also frequently exposed to multiple psychoactive medications during ICU admission and hospitalization including benzodiazepines and opioid medications which may increase the risk of psychoactive polypharmacy following hospital discharge. The associated impact on health resource utilization and risk of new benzodiazepine and opioid prescriptions is unknown. What is the burden of health resource utilization and odds of new prescriptions of benzodiazepines and opioids up to 1-year post-hospital discharge in critically ill patients with new antipsychotic prescriptions at hospital discharge? We completed a multi-center, propensity-score matched retrospective cohort study of critically ill adult patients. The primary exposure was administration of ≥1 dose of an antipsychotic while the patient was admitted in the ICU and ward with continuation at hospital discharge and a filled outpatient prescription within 1-year following hospital discharge. The control group was defined as no doses of antipsychotics administered in the ICU and hospital ward and no filled outpatient prescriptions for antipsychotics within 1-year following hospital discharge. The primary outcome was health resource utilization (72-hour ICU readmission, 30-day hospital readmission, 30-day emergency room visitation, 30-day mortality). Secondary outcomes were administration of benzodiazepines and/or opioids in-hospital and following hospital discharge in patients receiving antipsychotics. 1,388 propensity-score matched patients were included who did and did not receive antipsychotics in ICU and survived to hospital discharge. New antipsychotic prescriptions were not associated with increased health resource utilization or 30-day mortality following hospital discharge. There was increased odds of new prescriptions of benzodiazepines (adjusted odds ratio [aOR] 1.61 [95%CI 1.19-2.19]) and opioids (aOR 1.82 [95%CI 1.38-2.40]) up to 1-year following hospital discharge in patients continuing antipsychotics at hospital discharge. New antipsychotic prescriptions at hospital discharge are significantly associated with additional prescriptions of benzodiazepines and opioids in-hospital and up to 1-year following hospital discharge.

Economic and clinical burden associated with respiratory viral infections after allogeneic hematopoietic cell transplant in the United States.

BackgroundAllogeneic hematopoietic cell transplant (allo‐HCT) recipients are at increased risk for respiratory viral infections (RVIs), which invoke substantial morbidity and mortality. Limited effective antiviral options and drug resistance often hamper successful RVI treatment, creating additional burden for patients and the health care system.MethodsUsing an open‐source health care claims database, we examined differences in clinical outcomes, health resource utilization, and total reimbursements during the 1‐year period following allo‐HCT in patients with and without any RVI infection (respiratory syncytial virus, influenza, parainfluenza virus, and human metapneumovirus). RVIs were diagnosed at any time ≤1 year after allo‐HCT and identified by International Classification of Disease codes. Analyses were stratified by the presence or absence of acute or chronic graft‐versus‐host disease (GVHD).ResultsThe study included 13 363 allo‐HCT patients, 1368 (10.2%) of whom had a diagnostic code for any RVI. A higher proportion of patients with any RVI had pneumonia ≤1 year after allo‐HCT compared to patients without any RVI, with or without GVHD. Patients with any RVI had higher all‐cause mortality risk, longer length of post‐allo‐HCT hospital stay, higher readmission rate, and higher number of hospital days after allo‐HCT compared to patients without the infection (all p < .05). Total unadjusted median reimbursements were higher for those with any RVI and each specific RVI assessed than those without the specific infection, with or without GVHD.ConclusionAllo‐HCT patients with RVIs had significantly worse clinical outcomes and increased health resource utilization and reimbursements during the year following allo‐HCT, with or without GVHD.

Burden of tyrosine kinase inhibitor failure in Chinese chronic myeloid leukemia patients: a systematic literature review.

Aim: To conduct a systematic literature review of real-world evidence on the burden of tyrosine kinase inhibitor (TKI) failure in Chinese patients with chronic myeloid leukemia (CML). Methods: We identified 155 references in Chinese- and English-language journals from 2001 to 2021. Results: The age-adjusted mortality rate in Chinese CML patients was decreasing. Imatinib treatment had a higher annual treatment failure risk than nilotinib (0.199 vs 0.041). Patients with TKI treatment failure tended to be young (median: 38.6years), have progressive disease (44.3%) and harbor BCR-ABL1 mutations (51.6%). The disease burden of TKI treatment failure included reduced health outcomes and increased health resource utilization and costs. Conclusion: CML relapse cases could continuously rise in China due to increasing TKI treatment failure over extended survival.

Abstract 13619: Obese Patients With New Onset Atrial Fibrillation/Flutter Have Higher Rates of Hospitalization, Cardioversion, and Ablation

Atrial fibrillation (AF) is the most common arrhythmia and can lead to frequent healthcare encounters. Obesity is a rapidly growing epidemic, and greater than one third of all adults in the USA are obese. Additionally, obese patients have over twice the prevalence of AF compared to the non-obese. Despite the frequency of these conditions, there is limited research assessing the relationship between obesity and healthcare resource utilization (HRU) in AF patients. We hypothesized that obese patients with new onset atrial fibrillation/flutter (AFL) would have higher AF/AFL related hospitalizations and procedures compared to non-obese patients. We utilized MarketScan® claims data to select patients with new onset atrial fibrillation or atrial flutter in 2017 and 2018 and classified them according to diagnosis codes as obese or non-obese. We then stratified by the diagnosis of obesity. There were 95,314 patients with new onset atrial fibrillation/flutter, which included 72,218 (76%) who were non-obese and 23,096 (24%) who were obese. There were significantly more males than females (64.4% vs. 35.6%). The average age was similar at 54.4 (+/- 0.04) in the non-obese and 54.6 (+/- 0.06) in the obese cohort. The rate of hospitalizations (35.9% vs. 24.8%, p&lt;0.001), cardioversions (16% vs. 10%, p&lt;0.001), and ablation procedures (10% vs. 7%, p&lt;0.0001) were significantly higher in the obese versus non-obese cohort. Obese patients with new onset AF/AFL had significantly higher HRU than non-obese patients. This increased health resource utilization increases the cost of care in such patients and future studies should concentrate on understanding the reasons for this difference.

Pain Management in Chronic Pancreatitis: Summary of Clinical Practice, Current Challenges and Potential Contribution of the M-ANNHEIM Classification.

Abdominal pain, diarrhea with weight loss, and endocrine insufficiency represent the dominant symptoms of chronic pancreatitis (CP). High intensity of pain and constant pain have been shown to reduce quality of life in CP and may result in disability and increased health resource utilization. Various basic challenges and unanswered questions still exist regarding the treatment of pain in CP. Recently, limited evidence has been gained that early surgery for painful disease might be associated with better treatment results. Thus, timing of pancreatic surgery in painful disease represents a major issue that needs to be clarified in future studies. In this context, surveillance of patients is necessary in clinical practice. It appears that a generally accepted classification of the disease represents a major requirement for inter-institutional comparison of data with future progress in clinical research. Among recently proposed classification systems, the M-ANNHEIM classification system of CP with its recently presented M-ANNHEIM Surgery Score might be a useful tool to picture the course of the disease and to monitor treatment results. Future research is required to clarify the possible role of this system in the management of pain in CP. In the present article, we provide an overview of current status, challenges, and unanswered questions in the treatment of pain in CP, and we demonstrate the potential benefits of the M-ANNHEIM classification system in the management of painful CP.

Increased Health Resource Utilization with the Introduction of Matrix for First-Line Treatment of Primary Central Nervous System Lymphoma

Introduction: Prior to 2016, Primary Central Nervous System Lymphoma (PCNSL) was treated using High-Dose Methotrexate (HD-MTX) +/- Cytarabine. Since 2016, the MATRix regimen (HD-MTX, Cytarabine, Thiotepa, Rituximab) was adopted based on the IELSG32 study (Ferreri et al. Lancet 2016). Information on health resource utilization (HRU) for the MATRix regimen compared to prior standards of care is limited. We sought to investigate HRU in PCNSL patients treated with the MATRix regimen compared to other HD-MTX regimens at a single institution. Methods: Adults (≥18years) with a diagnosis of PCNSL between January 1, 2009 and December 31, 2018 and treated with a HD-MTX regimen were included. All patients were treated in Hamilton, ON, Canada and had complete treatment data available. Patient characteristics, including age, sex, malignancy type, chemotherapy regimen, length and number of hospitalizations, and transfusion data were obtained through electronic health records. Patients treated for relapsed/refractory disease were excluded. Patients were categorized based on the treatment regimen received. Results: Fifty-one patients [20 (39.2%) female] were included. Median age was 69.0 [range, 41 to 87]. 17 (33.3%) patients were treated with MATRix, 14 (27.5%) with HD-MTX + Cytarabine, and 18 (35.3%) with HD-MTX only. 2 (3.9%) patients were treated with other drug regimens and excluded from analysis. The mean overall length of stay (LOS) was 92.6 days [95%CI, 48.9 to 136.3] in the MATRix group, 70.5 days [95%CI, 37.4 to 103.6] in the HD-MTX + Cytarabine group, and 40.6 days [95%CI, 25.6 to 55.5] in the HD-MTX group. Mean LOS was significantly shorter in the HD-MTX group compared to MATRix group (P = 0.04), all other comparisons for LOS were not statistically significant. The mean number of red blood cell units transfused per patient was 11.5 [95%CI, 8.4 to 14.5] in the MATRix group, 10.6 [95%CI, 3.5 to 17.8] in the HD-MTX + Cytarabine group, and 1.9 [95%CI, 0.7 to 3.2] in the HD-MTX group. There were significantly more red blood cell units transfused per patient with MATRix compared to HD-MTX (RR 1.54, 95%CI, 1.05 to 2.27, P = 0.03) but not HD-MTX + Cytarabine compared to HD-MTX (RR 1.40, 95%CI, 0.92 to 2.15, P = 0.12) or HD-MTX + Cytarabine compared to MATRix (RR 1.10, 95%CI, 0.86 to 1.40, P = 0.45). The mean number of pooled platelet units transfused was 8.1 [95%CI 4.0 to 12.1] for the MATRix group, 5.3 [95%CI, 0.9 to 9.7] for the HD-MTX + Cytarabine group, and 0.7 [95%CI, 0 to 1.5] for the HD-MTX group. There were significantly more platelet blood cell units transfused per patient in the MATRix group compared to the HD-MTX group (RR 2.47, 95%CI, 1.24 to 4.92, P = 0.01), all other comparisons were not significant. Conclusion: Our institution observed that the HRU, assessed through LOS, and number of red blood cell and platelet transfusions, in PCNSL patients was significantly higher for patients treated with a MATRix regimen in comparison to a HD-MTX only regimen but not a HD-MTX + Cytarabine regimen. These findings highlight important implications for assessing the impact to patients and systems when a new standard of care is adopted. Additionally, beyond drug acquisition costs these considerations may make the adoption of regimes such as MATRix prohibitive for resource limited settings. Disclosures Hillis: Roche: Honoraria.

Readmissions among patients with COVID-19.

Hospital readmissions are associated with poor patient outcomes and increased health resource utilisation. The need to study readmission patterns is even bigger during a pandemic because the burden is further stretching the healthcare system. We reviewed the initial hospitalisation and subsequent readmission for 19 patients with confirmed COVID-19 in the largest statewide hospital network in Rhode Island, US, from March 1st through April 19th, 2020. We also compared the characteristics and clinical outcomes between readmitted and non-readmitted patients. Of the 339 hospitalised patients with COVID-19, 279 discharged alive. Among them, 19/279 were readmitted (6.8%) after a median of 5days. There was a significantly higher rate of hypertension, diabetes, chronic pulmonary disease, liver disease, cancer and substance abuse among the readmitted compared with non-readmitted patients. The most common reasons of readmissions happening within 12days from discharge included respiratory distress and thrombotic episodes, while those happening at a later time included psychiatric illness exacerbations and falls. The length of stay during readmission was longer than during index admission and more demanding on healthcare resources. Among hospitalised patients with COVID-19, those readmitted had a higher burden of comorbidities than the non-readmitted. Within the first 12days from discharge, readmission reasons were more likely to be associated with COVID-19, while those happening later were related to other reasons. Readmissions characterisation may help in defining optimal timing for patient discharge and ensuring safe care transition.

Does obesity affect the short-term outcomes after cardiothoracic surgery in adolescents with congenital heart disease?

Obesity is a modifiable, independent risk factor for mortality and morbidity after cardiovascular surgery in adults. Our objective was to evaluate the impact of obesity on short-term outcomes in adolescents undergoing surgery for congenital heart disease (CHD). This retrospective chart review included patients 10-18 years of age who underwent CHD surgery. Our exclusion criteria were patients with a known genetic syndrome, heart transplantation, and patients with incomplete medical records. The clinical data collected included baseline demographics and multiple perioperative variables. Charting the body mass index in the Centers for Disease Control and Prevention growth curves, the entire cohort was divided into three categories: obese (>95th percentile), overweight (85th-95th percentile), and normal weight (<85th percentile). The composite outcome included survival, arrhythmias, surgical wound infection, acute neurologic injury, and acute kidney injury. The study cohort (n = 149) had a mean standard deviation (SD), body mass index (BMI) of 22.6 ± 6.5 g/m2, and 65% were male. There were 27 obese (18.1%), 24 overweight (16.1%), and 98 normal weight (65.8%) patients. Twenty-seven (18%) patients had composite adverse outcomes. Overweight and obese patients had significantly higher adverse outcomes compared with normal weight patients (odds ratio (OR): 2.9; confidence interval (CI): 1-8.5, p = 0.04 and OR: 3; CI: 1-8.5, p = 0.03, respectively). In multivariate analysis, obesity was an independent predictor of adverse outcome in our cohort (p = 0.04). Obesity is associated with short-term adverse outcome and increased health resource utilisation in adolescents following surgery for CHD. Further studies should evaluate if intervention in the preoperative period can improve outcomes in this population.

The Role of Rehabilitation in Patients Receiving Hospice and Palliative Care

Patients receiving palliative and hospice care experience high levels of functional loss, dependency on activities of daily living, and impairment in mobility. Physical disability affects important aspects of life, oftentimes leading to depression, poor quality of life, increased caregiver needs, increased health resource utilization, and institutionalization. Physical strength, the number of hours spent in bed, and the ability to do what one wants are important indicators of quality of life for patients with cancer and their families. Progressive debility with a sense of being a burden has been cited in the literature as a reason for desiring death among these patients. This perception of increased dependence on others serves as a strong predictor for a patient's interest in the physician aid in dying (PAD). This highlights the desire and willingness of most palliative and hospice care patients to remain physically independent during the course of their disease. Several studies have shown that maintaining the most optimal level of functional ability, especially mobility, for as long as possible is one of the main benefits of rehabilitation in the palliative and hospice care settings. Studies demonstrate that rehabilitation in patients receiving hospice and palliative care can reduce the burden of care for families and caregivers and improve patient's quality of life, sense of well-being, as well as control of pain and non-pain symptoms.

From skeletal muscle weakness to functional outcomes following critical illness: a translational biology perspective

Intensive care unit acquired weakness (ICUAW) is now a well-known entity complicating critical illness. It increases mortality and in the critical illness survivor it is associated with physical disability, substantially...

Can asthma be well controlled with NAEPP guideline care in morbidly obese children? The Breathmobile

BackgroundObesity is thought to be associated with poor asthma control, increased health resource utilization, and reduced responsiveness to inhaled corticosteroids. ObjectiveBased on previous experience, our hypothesis was that by improved access to comprehensive guideline care, outcomes in normal weight would be comparable in obese children with asthma. MethodsThis was a retrospective cohort study of predominately Hispanic children (3-18 years of age) in underserved areas of Orange County, California, who enrolled in the Breathmobile Program from 2003 to 2012. Outcomes were examined by using Cox regression and generalized estimating equations analyses, adjusted for potential confounding factors. ResultsClinical outcomes in more than 1,200 children followed up for a mean of 6 visits (standard deviation [SD] = 2.2) across 403 days (SD = 112) were improved, on average, regardless of body mass index (BMI). Morbidly obese (MOB) patients were able to achieve significant reductions of approximately 60% or more in report of emergency department (ED) visits, hospitalizations, school absenteeism, usual exercise limitations, and exacerbations to levels that were comparable those of normal weight (NW) patients. The importance of close follow-up, particularly for the MOB patient, was evidenced by achieving 80% cumulative probability of well controlled asthma by visit 3, similar to patients in lower BMI risk groups with good adherence, when the visit interval did not exceed 90 days. These outcomes were achieved across all BMI groups with similar mean step of therapy, adjusted for severity (P < .001). ConclusionAccess to effective community-based care where trust, education, and continuity of care consistent with National Asthma Education and Prevention Program (NAEPP) guidelines is possible, as demonstrated by the Breathmobile Program, can provide an opportunity for children with asthma in all BMI categories to achieve well-controlled disease.

Incidence, Predictors, and In-Hospital Outcomes of Transcatheter Aortic Valve Implantation After Nonelective Admission in Comparison With Elective Admission: From the Nationwide Inpatient Sample Database

Candidates for transcatheter aortic valve implantation (TAVI) are generally older with multiple co-morbidities and are therefore susceptible to nonelective admissions before scheduled TAVI. Frequency, predictors, and outcomes of TAVI after nonelective admission are under-explored. We queried the Nationwide Inpatient Sample database, an administrative database, from January 2012 to September 2015 to identify hospitalization in those age ≥50 who had transarterial TAVI. A propensity-matched cohort was created to compare the outcomes between nonelective and elective admission who had TAVI. The primary outcome was in-hospital mortality. A total of 9,521 TAVI admissions were identified during the study period. Of these admissions, 22.3% were nonelective admissions. Pulmonary circulation disorders (adjusted odds ratio [aOR] 1.38), anemia (aOR 1.54), congestive heart failure (aOR 1.37), chronic kidney disease (aOR 1.28; all p <0.001), and atrial fibrillation (aOR 1.17, p = 0.006) were independent risk factors for nonelective admission. In a propensity-matched cohort (1,683 admissions in each cohort), in-hospital mortality was similar (4.0% vs 2.8%, p = 0.052). Nonelective admissions had higher rates of acute myocardial infarction (5.2% vs 0.7%), fatal arrhythmia (9.4% vs 6.0%), acute kidney injury (25.9% vs 17.1%), respiratory failure requiring intubation (0.26% vs 0.19%), cardiogenic shock (5.1% vs 2.1%; all p <0.001), and bleeding requiring transfusion (13.1% vs 10.1%, p = 0.006) during the index-hospitalization. Hospital length of stay (11.4 days vs 6.5 days, p <0.001) and hospital cost ($68,669 vs $57,442, p <0.001) were both increased in nonelective admissions. Nonelective admission accounted for approximately one-fifth of total TAVI with significantly different cohort profiles. Our results suggest that nonelective TAVI has higher adverse outcomes and increased health resource utilization. Expedition in TAVI process in high-risk cohorts may result in better outcomes.

Contrast-induced nephropathy: Pathophysiology, risk factors, and prevention.

Contrast-induced acute kidney injury is a common iatrogenic complication associated with increased health resource utilization and adverse outcomes, including short- and long-term mortality and accelerated progression of preexisting renal insufficiency. The incidence of contrast-induced nephropathy (CIN) has been reported to range from 0% to 24%. This wide range reported by the studies is due to differences in definition, background risk factors, type and dose of contrast medium used, and the frequency of other coexisting potential causes of acute renal failure. CIN is usually transient, with serum creatinine levels peaking at 2-3 days after administration of contrast medium and returning to baseline within 7-10 days after administration. Multiple studies have been conducted using variety of therapeutic interventions in an attempt to prevent CIN. Of these, careful selection of patients, using newer radiocontrast agents, maintenance of hydration status, and avoiding nephrotoxic agents pre- and post-procedure are the most effective interventions to protect against CIN. This review focuses on the basic concepts of CIN and summarizes our recent understanding of its pathophysiology. In addition, this article provides practical recommendations with respect to CIN prevention and management.

Healthcare burden of obstructive sleep apnea and obesity among asthma hospitalizations: Results from the U.S.-based Nationwide Inpatient Sample

BackgroundStudies have highlighted the significant comorbidities of both obesity and obstructive sleep apnea (OSA) among asthma patients in outpatient settings, but such data in the inpatient setting is sparse. MethodsUsing 2009–2011 U.S. Nationwide Inpatient Sample; survey-weighted regression analyses were conducted to address the role of obesity, OSA, and both obesity and OSA on length of stay (LOS), total hospital charges, need for respiratory therapy, and disposition among adults with primary asthma hospitalization (n = 179,789). ResultsMales had a higher prevalence of OSA than females (5.23% vs. 3.88%), while females had a higher prevalence of obesity (17.21% vs. 8.95%) and both obesity and OSA (7.11% vs. 6.19%). Increased hospital LOS was associated with presence of obesity (incidence rate ratio [IRR] males = 1.07, IRR females = 1.08), OSA (IRR males = 1.07, IRR females = 1.14), and both obesity and OSA (IRR males = 1.19, IRR females = 1.24). Increased total hospital charges was related to obesity (8.64% for males and 9.61% for females), OSA (15.39% for males and 19.13% for females), and both comorbidities (24.94% for males and 28.50% for females). Presence of OSA alone increased odds of need for respiratory therapy for males (odds ratio [OR] = 2.56) and females (OR = 3.22), as did presence of both comorbidities (OR males = 2.85, OR females = 3.60). Odds of routine disposition was lower among females with both comorbidities (OR = 0.82). ConclusionCompared to obesity alone, OSA and both obesity and OSA are associated with increased health resource utilization and poorer inpatient outcomes. This demonstrates the need for further clinical investigations of early detection of OSA among such at-risk populations.