Inpatient Medical Services Research Articles

A Kansei engineering-based decision-making method for offline medical service quality evaluation with multidimensional attributes

The evaluation of doctors’ offline medical service quality plays a vital role in evaluating hospital performance. There are two challenges that need to be addressed: (1) Currently, telephone follow-up and questionnaire surveys are the main methods for evaluating the quality of offline (mainly outpatient and inpatient) medical services in hospitals. However, these methods suffer from drawbacks such as low efficiency and resource consumption. (2) There are certain limitations to determining attribute dimensions and weighting patient evaluation attributes based solely on word frequency. To this end, this study proposes a Kansei engineering-based decision-making method for offline medical service quality evaluation with multidimensional attributes. First, this study constructs a medical Kansei lexicon based on speed and cosine similarity. Second, a concept of Kansei utility values is been defined to represent attribute values in medical service quality evaluation. Additionally, this study builds upon the Kano model to obtain the Kano classification of each attribute. On that basis, a novel approach to obtaining the implicit importance of the attributes is proposed. Thus, the weight vector of the attributes can be calculated as the combination of explicit and implicit importance. Finally, the evaluation result is obtained by using the multiattribute decision-making method. The effectiveness of the proposed method is verified through an analysis of online reviews from Haodf.com. The case study reveals that offline patients consider medical ethics and communication skills as the ”must-be” dimension of attributes, medical competence as a one-dimensional attribute, and medical advice and prescriptions as the attractive dimension of attributes. A comparative analysis with the traditional method is conducted to demonstrate the importance of dimensional analysis for offline medical service quality evaluation. The main contributions of this study include the following: (1) A medical Kansei lexicon is constructed based on Kansei engineering, and (2) a novel decision-making framework for medical service evaluation based on both appearance and implicit importance is constructed.

Impact of COVID-19 on health-related quality of life in patients with cardiovascular disease: A cross-sectional study.

The COVID-19 pandemic disrupted healthcare access for cardiovascular patients, potentially worsening their health outcomes and quality of life through both medical and psychological impacts. This cross-sectional study was conducted to assess the quality of life of patients with cardiovascular disease before and after the COVID-19 pandemic. The work was conducted from January 9 to April 28, 2023, in Almaty city and the Almaty region. 3026 outpatients with cardiovascular pathology participated in the survey using a standardised European Quality of Life Questionnaire. The study utilized cluster, frequency analysis, and discrete statistics to analyze the impact of COVID-19 on quality of life parameters, revealing significant changes in anxiety and depression among cardiovascular patients, resulting in reduced quality of life (from 0.3% to 5.5% and 0.4; to 7.5% in the categories of extremely severe and severe manifestations, respectively). An analysis of the nosological structure of cardiovascular diseases in the study group was performed and revealed that coronary heart disease occurred in 51.6% of cases, arterial hypertension in 88%, and diabetes mellitus in 34.6%. The availability of both outpatient and inpatient medical services in Almaty region and Almaty city was also assessed, and their comparative analysis was conducted, during which it was found that the need for these services in the district settlements is 10% and 12% higher, respectively, than in the city, which is particularly important for understanding the effectiveness of the public health system in the context of the COVID-19 pandemic, both at the regional and republican levels. This study is of practical importance for health care workers, as it allows assessing the impact of the COVID-19 pandemic on the quality of life of patients with cardiovascular diseases, which provides an opportunity to develop effective rehabilitation protocols and psychological support for this vulnerable category.

Prognostic impact of cardiac events in asymptomatic mitral regurgitation

Abstract Background Mitral regurgitation (MR) is the most common valvular heart disease in adults and is associated with increased morbidity and mortality. Treatment recommendations of degenerative MR have been liberalized, however, the role of asymptomatic patients is still insufficiently defined. Purpose The purpose of this study were to evaluate the prevalence of cardiac events in a large asymptomatic MR cohort, based on health insurance data analysis, in comparison with healthy propensity score-matched general population and to define the prognostic impact of such cardiac events on ten-year survival. Methods We retrospectively analyzed health insurance claims data from Germany’s second largest health insurance fund, which maintains longitudinal data on outpatient and inpatient medical services for 8.7 million German residents. We included all patients with an outpatient diagnosis of MR (I34.0) in a minimum of two quarters during a calendar year and first recorded diagnosis between 2008 and 2011. To identify an asymptomatic MR cohort (study group), all patients with at least one complication attributable to MR / mitral valve intervention during the incidence quarter of MR were excluded. Ten-year outcomes were compared between study group vs. age- and sex-matched healthy control group. Cardiac events of interest were new congestive heart failure, new-onset atrial fibrillation, pulmonary hypertension, or cardiac decompensation. Results A total of 56.577 (62.7%) asymptomatic MR patients were identified from the whole cohort of 90.245 individuals with a newly diagnosed MR in the BARMER database. During a ten-year follow-up, 26.282 (46.5%) patients in the study group experienced at least one cardiac event vs. 11.763 (20.8%) individuals in the control group (OR: 3.31, 95%CI: 0.251-0.262, P<0.0001). The occurrence of at least one cardiac event (i.e., congestive heart failure, new-onset atrial fibrillation, pulmonary hypertension or cardiac decompensation) in the study group was associated with a significantly worse ten-year survival as compared to the control group. The risk of cardiac events was age- and sex-dependent, while female patients with an asymptomatic MR had a lower risk as compared to males in all age groups (OR: 0.38, 95%CI: -1.193- -0.754, P<0.0001). Only 1.530 (2.7%) patients underwent mitral valve (MV) intervention in the study group during ten-year follow-up. Conclusions Our study reveals high incidence of asymptomatic MR in a representative cohort of health insurance claims data in Germany. Every second patient with an asymptomatic MR experiences at least one cardiac event during a ten-year follow-up period that is associated with a significantly worse survival. The definition of asymptomatic MR cohort at risk of developing cardiac events may potentially improve early treatment strategies and lead to better outcome in the future.Abstract picture

Care models for older people based on a case study-Geriatrics as an active discipline

Geriatrics can enable and monitor aholistic care of older people through acomprehensive geriatric assessment in a structured way. Therefore, it must be integrated much more closely with preventive, rehabilitative and acute care units. Geriatrics are not seen in any aspects as areplacement for general practitioners or in-hospital structures but much more as asupplement to them. With its function-oriented concept, geriatrics can best coordinate the demographically necessary triage between prevention, acute treatment, rehabilitation and palliative care, thus avoiding undertreatment and overtreatment. This can only succeed in collaboration with general practitioners and specialist colleagues. The article categorizes geriatric care structures, such as preventive home visits, acute complex medical treatment, delirium prevention, outpatient and inpatient rehabilitation services based on acase example and makes proposals for structural changes that urgently need to be considered in the current healthcare reform, such as outpatient geriatric centers (AGZ).

The impact of medical insurance and old-age security on the utilization of medical services by the older population with disabilities

ObjectiveIn this study, the impact of medical insurance and old-age security on the use of medical services by the older population with disabilities is analyzed. A reference for decision makers is provided to improve medical and old-age security policies and enhance the use of medical services by the older population.MethodsData were drawn from 3,737 older people with disabilities aged 65 years or above from the 2018 China Longitudinal Healthy Longevity Survey. A two-part model based on social ecological theory was used for both analysis and group prediction.ResultsIn terms of the use of outpatient medical services, old-age pension significantly increased the probability of outpatient visits for this population group (P < 0.05). Urban employee/resident medical insurance, the new rural cooperative medical insurance, and retirement pension significantly affected medical expenses. In terms of the use of inpatient medical services, the new rural cooperative medical insurance and retirement pension significantly influenced the choice of inpatient medical services; retirement pension increased inpatient medical expenditure (p < 0.01). The expected average probability of hospitalization, unconditional expected cost, and conditional expected cost for the older population with disabilities were 49.5%, RMB 6629.31, and RMB 3281.51, respectively. Both conditional and unconditional expected costs were significantly higher for older people with disabilities with the following attributes: male, married, no less than three chronic conditions, and unassisted daily care; costs were lower for older people with disabilities who are female, not married, had less than three chronic conditions, and had a spouse, child, or other caregiver.ConclusionMedical insurance and old-age security can significantly promote the utilization of medical services by the older population with disabilities. It is therefore recommended to focus on strengthening the support and health management of these people who are unattended to improve the effective use of health services and better meet their needs.

Effect of Implementing an Informatization Case Management Model on the Management of Chronic Respiratory Diseases in a General Hospital: Retrospective Controlled Study.

The use of chronic disease information systems in hospitals and communities plays a significant role in disease prevention, control, and monitoring. However, there are several limitations to these systems, including that the platforms are generally isolated, the patient health information and medical resources are not effectively integrated, and the "Internet Plus Healthcare" technology model is not implemented throughout the patient consultation process. The aim of this study was to evaluate the efficiency of the application of a hospital case management information system in a general hospital in the context of chronic respiratory diseases as a model case. A chronic disease management information system was developed for use in general hospitals based on internet technology, a chronic disease case management model, and an overall quality management model. Using this system, the case managers provided sophisticated inpatient, outpatient, and home medical services for patients with chronic respiratory diseases. Chronic respiratory disease case management quality indicators (number of managed cases, number of patients accepting routine follow-up services, follow-up visit rate, pulmonary function test rate, admission rate for acute exacerbations, chronic respiratory diseases knowledge awareness rate, and patient satisfaction) were evaluated before (2019-2020) and after (2021-2022) implementation of the chronic disease management information system. Before implementation of the chronic disease management information system, 1808 cases were managed in the general hospital, and an average of 603 (SD 137) people were provided with routine follow-up services. After use of the information system, 5868 cases were managed and 2056 (SD 211) patients were routinely followed-up, representing a significant increase of 3.2 and 3.4 times the respective values before use (U=342.779; P<.001). With respect to the quality of case management, compared to the indicators measured before use, the achievement rate of follow-up examination increased by 50.2%, the achievement rate of the pulmonary function test increased by 26.2%, the awareness rate of chronic respiratory disease knowledge increased by 20.1%, the retention rate increased by 16.3%, and the patient satisfaction rate increased by 9.6% (all P<.001), while the admission rate of acute exacerbation decreased by 42.4% (P<.001) after use of the chronic disease management information system. Use of a chronic disease management information system improves the quality of chronic respiratory disease case management and reduces the admission rate of patients owing to acute exacerbations of their diseases.

Assessment of the dynamics of inpatient health care delivery in Poland before and throughout the COVID-19 pandemic

A situation of emergency involving the whole population introduces changes in the dynamics of the health services that are provided. The magnitude of these shifts should be also linked to the medical speciality within which the health benefits are delivered. The aim of the paper was to identify changes in tendencies in inpatient medical service delivery during the COVID-19 pandemic by medical specialties. On the basis of a database extracted for in-patient treatment received from the public payer, a retrospective analysis was carried out. Comparing the values of the dynamics of the services provided in each medical speciality, the period before the COVID-19 pandemic was collated to the years of the pandemic (2020–2021). In the period before COVID-19, positive patient dynamics were observed in more than half of the specialities. Between 2020 and 2021, virtually all specialties reversed the trend and negative dynamics were recorded. The dynamics in 2021 indicate a process of return to the values from 2015 to 2019. Emergency situation has affected the dynamics of healthcare provision in different specialities to various extent. The most resistant to the negative impulses of the state of emergency were the areas that are strictly organisationally and financially defined (e.g. the group of “therapeutic and drug programmes”).

Comorbidities, healthcare use, and contact with healthcare transition services in older veterans after incarceration.

The Health Care for Reentry Veterans (HCRV) program was established to support community reintegration for veterans after incarceration. Yet, it is unclear how those with and without HCRV contact differ. We sought to evaluate differences in medical and psychiatric conditions and healthcare utilization among mid-to late-life reentry veterans who did and did not receive HCRV outreach. Study participants were veterans aged ≥50 years who qualified for Medicare fee-for-service, had experienced incarceration for ≥1 year, and were released from incarceration between October 1, 2006, and September 30, 2018 (N = 9733). Using VA and Medicare claims data, we compared prevalence of medical and psychiatric diagnoses, and use of emergency, inpatient, and outpatient medical and mental health services up to 12 months after release between those with and without HCRV contact. Veterans with HCRV contact (35.5%) had significantly higher rates of psychiatric conditions and medical conditions related to substance use (e.g., liver disease) compared to veterans without HCRV contact. Average time between release and first healthcare service use was significantly lower for HCRV veterans (36.5 ± SD 59.5 days) versus non-HCRV veterans (58.9 ± SD 77.5 days) and HCRV veterans were more likely to utilize the emergency department, inpatient and outpatient mental health services, and inpatient medical services. HCRV reaches older reentry veterans with a large burden of mental health and substance use disorders. However, levels of multimorbidity were high among all older reentry veterans, pointing to a need to develop specialized geriatric models of care for this reentry population.

Association of Frailty with Healthcare Utilization for Patients over One Year Following Surgical Evaluation.

Characterize the distribution of healthcare utilization associated with pre-operative frailty in the year following evaluation by a surgeon. Frailty is associated with increased morbidity, mortality, and costs for surgical patients. However, the total financial burden for frail patients beyond the index surgery and inpatient stay remains unknown. Prospective cohort assembled from February 2016 to December 2020 within a multi-hospital integrated healthcare delivery and finance system (IDFS), from patients evaluated with the Risk Analysis Index (RAI) of frailty. Inclusion criteria: age greater than 18, valid RAI, membership in the IDFS Health Plan. Data were stratified by frailty and surgical status. The mean (SD) age was 54.7 (16.1) and 58.2% female of the cohort (n=86,572). For all patients with reimbursement for surgery (n=53,856), frail and very frail patients incurred respective increases of 8% ( P =0.027) and 29% ( P <0.001) on utilization relative to the normal group. Robust patients saw a 52% ( P <0.001) decrease. This pattern was more pronounced in the cohort without surgery (n=32,716). The increase over normal utilization for frail and very frail patients increased to 23% ( P =0.004) and 68% ( P <0.001), respectively. Utilization among robust patients decreased 62% ( P <0.001). Increases among the frail were primarily due to increased inpatient medical and post-acute care services (all P <0.001). Patient frailty is associated with increased total healthcare utilization, primarily via increased inpatient medical and post-acute care following surgery. Quantifying these frailty-related financial burdens may inform clinical decision making as well as the design of value-based reimbursement strategies.

Impact of hospitalist comanagement on vascular surgery inpatient outcomes

ObjectiveIn recent years, hospitalists have been increasingly involved in the medical management of hospitalized surgical patients. This trend has been impacted by the goal of offloading inpatient care from the primary care provider in addition to the presence of an increasing burden of inpatient comorbidities and broader trends in multidisciplinary team-based care of the surgical patient. Multiple studies have demonstrated the clinical benefits associated with the implementation of a hospitalist comanagement service for surgical patients, whereas others have highlighted increases in cost and strain on understaffed medical teams. We aimed to assess the impact of the implementation of a dedicated hospitalist comanagement agreement on outcomes in an academic medical center vascular surgery inpatient service. MethodsInstitutional review board approval was obtained before data collection. The inpatient database was queried for all admissions to the vascular surgery service between January 1, 2007, and December 31, 2017. Given that a hospitalist comanagement agreement was established in 2014, we collected data and compared cohorts admitted to the vascular surgery service before and after January 1, 2014. Patients admitted to the intensive care unit during their hospital stay were excluded, as the hospitalist team was not involved in intensive care unit patient care. We collected data on patient demographics, admission diagnosis, comorbid diseases, and clinical outcomes including hospital length of stay, cardiac morbidity, and mortality. Data were assessed via logistic regression models to investigate the impact on clinical outcomes after the start date of the hospitalist comanagement program. ResultsA total of 1438 patients were included in the analysis, including 866 pre- and 572 posthospitalist comanagement agreement. The mean age was 66.1 (standard deviation 14.0) years, similar in both groups. Overall, 822 (57.2%) patients were male, and 616 (42.8%) were female, similar in both groups. Overall, 67.5% were White, 25.6% Black, and 6.9% were classified as other race. The mean length of stay was 8.2 days overall and was lower in the comanagement group at 7.6 vs 8.6 days in the non-comanagement group (P = .0022). Overall 30-day mortality was 2.5%, similar in both groups (P = .36). The incidence of myocardial infarction was lower in the comanagement group at 2.6% vs 6.0% in the non-comanagement group (P = .0001). Logistic regression modeling controlling for comorbidities demonstrated a 61% odds reduction rate for cardiac events in patients who were comanaged by the hospitalist medicine team (P < .01). Linear regression modeling showed an overall reduced length of stay in the comanagement group by 1.45 days (P < .01) with benefits shown specifically for patients undergoing major amputation, thromboembolectomy, and those with infected vascular grafts (3.8, 7.4, and 8.4 fewer days, respectively). ConclusionsThe implementation of a hospitalist medicine comanagement care system for vascular surgery inpatients was associated with a decrease in cardiac events and hospital length of stay. These findings encourage future investigation into additional clinical benefits and financial implications of hospitalist comanagement in the vascular surgery inpatient population.

Catastrophic Out-of-Pocket Expenditure on Health: Evidence from the Regions in the Philippines

This study estimates Filipino’s catastrophic and impoverishing out-of-pocket (OOP) healthcare expenditures on a regional perspective to measure the effectiveness and progress of Philippines’ healthcare financing system in ensuring population protection from excessive and unequal healthcare costs. Observations are drawn from the most recent household-based survey in the Philippines, 2018 and 2021 Family Income and Expenditure Survey, and grouped by four major regions: National Capital Region, the rest of Luzon, Visayas, and Mindanao region. From 2018 to 2021, results showed that the distribution of catastrophic OOP healthcare expenditures decreases while depth of these payments increases across the four major regions. The highest incidences of these catastrophic payments were found in the rest of Luzon and Visayas regions, while the highest intensities were found in Mindanao region. Despite medicines and pharmaceuticals products dominance on OOP healthcare expenditures, payment on inpatient medical services drives the catastrophic expenditures of households. Aside, deepening poverty caused by healthcare payments were more evident in households residing in Mindanao regions, thus exposing this Filipino families to financial risk and poverty threats. Logistic regression analysis showed that aging households head, employment, and socio-economic status are significant and common factors affecting the likelihood of incurring excessive health expenditures across the regions. The risk of catastrophic and impoverishing effects of healthcare expenditures persists in the country. Low levels of catastrophic OOP healthcare expenditures may indicate that disadvantaged households focused on spending on basic necessities and struggle to afford healthcare due to high costs amid COVID 19, leading to foregone treatment. Thus, continuous implementation of fair and innovative ways of financing the healthcare system to reduce the financial burden of OOP payments on Filipino households is recommended.

Oncology hospitalist impact on hospice utilization.

Unplanned hospitalizations among patients with advanced cancer are often sentinel events prompting goals of care discussions and hospice transitions. Late referrals to hospice, especially those at the end of life, are associated with decreased quality of life and higher total health care costs. Inpatient management of patients with solid tumor malignancies is increasingly shifting from oncologists to oncology hospitalists. However, little is known about the impact of oncology hospitalists on the timing of transition to hospice. To compare hospice discharge rate and time to hospice discharge on an inpatient oncology service led by internal medicine-trained hospitalists and a service led by oncologists. At Smilow Cancer Hospital, internal medicine-trained hospitalists were integrated into one of two inpatient medical oncology services allowing comparison between the new, hospitalist-led service (HS) and the traditional, oncologist-led service (TS). Discharges from July 26, 2021, through January 31, 2022, were identified from the electronic medical record. The odds ratio for discharge disposition by team was calculated by logistic regression using a multinomial distribution. Adjusted length of stay before discharge was assessed using multivariable linear regression. The HS discharged 47/400 (11.8%) patients to inpatient hospice, whereas the TS service discharged 18/313 (5.8%), yielding an adjusted odds ratio of 1.94 (95% CI, 1.07-3.51; p=.03). Adjusted average length of stay before inpatient hospice disposition was 6.83days (95% CI, 4.22-11.06) for the HS and 16.29days (95% CI, 7.73-34.29) for the TS (p=.003). Oncology hospitalists improve hospice utilization and time to inpatient hospice referral on an inpatient medical oncology service. Patients with advanced cancer are often admitted to the hospital near the end of life. These patients generally have a poor chance of long-term survival and may prefer comfort-focused care with hospice. In this study, oncology hospitalists discharged a higher proportion of patients to inpatient hospice with less time spent in the hospital before discharge.

Optimizing Healthcare Delivery: Analyzing the Relationship Between Inpatient Medical Record Return Time and Service Effectiveness at Ciremai Hospital

The medical record installation must maintain medical records correctly and appropriately, including the return of medical records. According to the Ministry of Health (2006), the standard for returning inpatient medical records is ≤ 2x24 hours after completion of treatment. Meanwhile, the standard of service effectiveness in the form of time for providing outpatient medical records according to Kepmenkes number 129 of 2008 is ≤ 10 minutes. The purpose of the study was to determine the relationship between inpatient medical record return time and service effectiveness. The research method used is quantitative with a cross-sectional design. The population is 220 medical records of post-inpatient patients who are controlled outpatients at Ciremai Hospital during January 2022. The total sample is 145 using the Slovin formula with the purposive sampling technique. Univariate analysis using frequency distribution and bivariate analysis using the Spearman rank correlation test are used because the data is not normally distributed. The results show that the average time to return inpatient medical records is 115,86 hours, the fastest time is 24 hours, and the longest time is 360 hours. The average service effectiveness in the form of outpatient medical record provision was 222,26 minutes; the fastest time was 3 minutes; and the longest time was 710 minutes. The Spearman rank correlation coefficient is 0,418 with a p-value of 0,000 ≤ 0,05. The conclusion is that there is a relationship with moderate correlation strength between inpatient medical record return time and service effectiveness, with a value of 0,418.

Assessment of a modified MINDS-based protocol for management of alcohol withdrawal syndrome on an inpatient medical service.

To determine if a novel symptom-based alcohol withdrawal syndrome (AWS) protocol in a US Veterans cohort leads to significant clinical improvements in patient outcomes and safety. Prior studies of AWS management, oftentimes using the revised version of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) index, have demonstrated the effectiveness of symptom-triggered therapy for AWS. The Minnesota Detoxification Scale (MINDS) is an alternative to the CIWA-Ar index but remains unevaluated outside of the intensive care unit (ICU) setting. This study assesses outcomes in AWS management prior to and after the implementation of a novel MINDS-based AWS protocol (SDAWP) utilizing a revised MINDS index (MINDS-rev) in an inpatient medical ward setting. Retrospective cohort study including encounters prior to (n = 342) and after (n = 338) the implementation of the protocol. Pre- and post-protocol encounters were selected by combinations of diagnostic codes and charting elements. Outcome measures of AWS management were obtained in both groups. The primary endpoint was median total benzodiazepine exposure. Secondary outcomes included median length of hospitalization, median duration of benzodiazepine administration, and the incidence of complications. The median total benzodiazepine exposure in the post-SDAWP group was significantly lower than the pre-SDAWP group (21.2 vs. 12.0 mg, p < 0.0001) and for a significantly shorter median duration of time (4.0 vs. 3.0 days, p < 0.0001). There was no significant difference in the median length of stay (4.0 vs. 4.0 days, p = 0.50). The incidence of delirium tremens (21 vs. 7, p = 0.01) and need for transfer to a higher level of care (33 vs. 12, p = 0.002) was significantly lower in the post-SDAWP group. The SDAWP has provided significant improvements in AWS management in our institution and may potentially serve as a template for wider use in other inpatient settings.

Brief description of current problems and ongoing reforms of healthcare systems in Greece, Bulgaria a nd Spain

The article is a description of the problems and reforms of the healthcare systems of Greece, Bulgaria, Spain. The range of existing problems includes the imperfection of management and financing of healthcare in these countries, which leads to a high level of co-financing of medical care by the population itself, a shortage of medical personnel and their uneven distribution within countries, the predominance of inpatient medical services, reduced availability (waiting time for medical care). In addition, Greece and Bulgaria have a high prevalence of risk factors for non-communicable diseases with weak or no screening programs. The countries listed above are implementing a number of reforms related to the management and financing of healthcare, and the availability of medical care. However, significant results of reform, with the exception of Spain, are not observed in these countries, including due to the lack of political agreement on the implementation of the necessary reforms.

Association between caregiver type and catastrophic health expenditure among households using inpatient medical services: using Korean health panel

BackgroundCaregiving services often place a financial burden on individuals and households that use inpatient medical services. Consequently, this study aimed to examine the association between the type of caregiver and catastrophic health expenditure among households utilizing inpatient medical services.MethodsData were extracted from the Korea Health Panel Survey conducted in 2019. This study included 1126 households that used inpatient medical and caregiver services. These households were classified into three groups: formal caregivers, comprehensive nursing services, and informal caregivers. Multiple logistic regression was used to analyze the association between caregiver type and catastrophic health expenditure (CHE).ResultsHouseholds receiving formal caregiving had an increased likelihood of CHE at threshold levels of 40% compared to those who received care from family (formal caregiver: OR 3.11; CI 1.63–5.92). Compared to those who received formal caregiving, households using comprehensive nursing services (CNS) had a decreased likelihood of CHE (CNS: OR, 0.35; CI 0.15–0.82). In addition, considering the economic value associated with informal care, there was no significant relationship between households received formal caregiving and informal caregiving.ConclusionThis study found that the association with CHE differed based on the type of caregiving used by each household. Households using formal care had a risk of developing CHE. Households using CNSs were likely to have a decreased association with CHE, compared to households using informal and formal caregivers. These findings highlight the need to expand policies to mitigate the burden on caregivers for households forced to use formal caregivers.

EE213 Long COVID-19 Associated with 5-Fold Increase in Total Medical Costs and Greater Use of Inpatient and Outpatient Services Compared to Non-Long COVID-19: An Analysis of Real-World Data

Assess real-world evidence data on the prevalence and impact of long COVID (LC) to establish a baseline for the value of potential therapeutic interventions. This study was a retrospective, longitudinal analysis of administrative claims from multiple payer channels spanning 4/1/2020-6/30/2022. Inclusion criteria: 1) ICD-10-CM diagnosis code of COVID-19 (U07.1) on or after 4/1/2020 (COVID-19 diagnosis date=index date), 2) 18+ years of age on index, and 3) at least -365/+30 days of continuous plan enrollment surrounding index. Employing a conservative LC definition, patients were classified as LC if they presented at least 1 claim ≥ 28 days following the index date which included both a COVID-19 diagnosis and ≥1 of 8 LC-related symptoms. LC and non-LC patients were compared on demographics, COVID-19 symptoms, healthcare utilization, and medical costs. Descriptive statistics were presented for outcomes, and bivariate tests of significance were used to assess differences between cohorts. Of 4,938,801 medically attended COVID-19 patients meeting inclusion criteria, 386,153 (7.8%) qualified as LC. The LC patients were older (Mean(SD) = 67.0(19.0) vs. 51.0(20.7)), were more likely to be female (65.1% vs. 60.4%), were in poorer health (Deyo-Charlson Comorbidity Index=3.51(3.24) vs. 1.47(2.45)), and presented greater baseline total medical expenditures ($39,769($60,401) vs. $15,275($35,640); p < 0.0001). On index, LC patients had a higher rate of LC-related symptoms, and in the 180-day post-index period, LC patients incurred increased total medical costs ($38,874($54,098) vs. $7,319($18,439); p < 0.001) and greater use of inpatient and outpatient medical services. Patients with LC presented elevated rates of symptoms and incurred 5-fold greater medical costs post-index compared to non-LC patients. This study is one of the first to longitudinally quantify the cost and symptom burden of LC in a real-world setting and helps to establish a baseline for the value of potential therapeutic interventions.

The Health Care Utilization and Medical Costs in Long-Term Follow-Up of Children Diagnosed With Leukemia, Solid Tumor, or Brain Tumor: Population-Based Study Using the National Health Insurance Claims Data.

Childhood cancer survivors are at a high risk of medical consequences of their disease and treatment. There is growing information about the long-term health issues of childhood cancer survivors; however, there are very few studies describing the health care utilization and costs for this unique population. Understanding their utilization of health care services and costs will provide the basis for developing strategies to better serve these individuals and potentially reduce the cost. This study aims to determine the utilization of health services and costs for long-term survivors of childhood cancer in Taiwan. This is a nationwide, population-based, retrospective case-control study. We analyzed the claims data of the National Health Insurance that covers 99% of the Taiwanese population of 25.68 million. A total of 33,105 children had survived for at least 5 years after the first appearance of a diagnostic code of cancer or a benign brain tumor before the age of 18 years from 2000 to 2010 with follow-up to 2015. An age- and gender-matched control group of 64,754 individuals with no cancer was randomly selected for comparison. Utilization was compared between the cancer and no cancer groups by χ2 test. The annual medical expense was compared by the Mann-Whitney U test and Kruskal-Wallis rank-sum test. At a median follow-up of 7 years, childhood cancer survivors utilized a significantly higher proportion of medical center, regional hospital, inpatient, and emergency services in contrast to no cancer individuals: 57.92% (19,174/33,105) versus 44.51% (28,825/64,754), 90.66% (30,014/33,105) versus 85.70% (55,493/64,754), 27.19% (9000/33,105) versus 20.31% (13,152/64,754), and 65.26% (21,604/33,105) versus 59.36% (38,441/64,754), respectively (all P<.001). The annual total expense (median, interquartile range) of childhood cancer survivors was significantly higher than that of the comparison group (US $285.56, US $161.78-US $535.80 per year vs US $203.90, US $118.98-US $347.55 per year; P<.001). Survivors with female gender, diagnosis before the age of 3 years, and diagnosis of brain cancer or a benign brain tumor had significantly higher annual outpatient expenses (all P<.001). Moreover, the analysis of outpatient medication costs showed that hormonal and neurological medications comprised the 2 largest costs in brain cancer and benign brain tumor survivors. Survivors of childhood cancer and a benign brain tumor had higher utilization of advanced health resources and higher costs of care. The design of the initial treatment plan minimizing long-term consequences, early intervention strategies, and survivorship programs have the potential to mitigate costs of late effects due to childhood cancer and its treatment.

Evolution of the Chief Medical Officer Role in Teaching Hospitals and Health Systems.

Clinical physician leaders have become an increasingly important asset to hospitals and hospital systems in a changing healthcare environment. Specifically, the role of the chief medical officer (CMO) has expanded and evolved amid the shift to value-based payment models and sharpened focus on patient safety, quality, community engagement, and equity in healthcare, as well as a global pandemic. In light of these changes, this study examined the transformation of CMOs and similar roles and evaluated the current needs, challenges, and responsibilities of clinical leaders today. The primary data source used in this analysis was a survey fielded to 391 clinical leaders in 290 Association of American Medical Colleges-member hospitals and health systems in 2020. In addition, this study compared responses to the 2020 survey with findings from two prior iterations of the survey from 2005 and 2016. The surveys collected information regarding demographics, compensation, administrative titles, qualifications for the position, and the scope of the role, among other questions. All surveys consisted of multiple-choice, free response, and rating questions. The analysis was conducted using frequency counts and percentage distributions. Thirty percent of eligible clinical leaders responded to the 2020 survey. Twenty-six percent of the clinical leader respondents identified as female. Ninety-one percent of the CMOs were members of the senior management team in their hospital or health system. CMOs reported that they were responsible for five hospitals, on average, with 67% indicating they were responsible for more than 500 physicians. This analysis provides hospital and health systems with insight into the expanding scope and complexity of CMOs as they take on greater leadership responsibilities within their institutions amidst a shifting healthcare landscape. In reflecting on our results, hospital leaders can understand the current needs, barriers, and responsibilities of today's clinical leaders.

Acute Hyperactive Delirium followed by Excited Catatonia: A case study

Acute Hyperactive Delirium followed by Excited Catatonia: A case studyOluwole A Babatunde, MD, Frank Clark, MD, Jessica Hill, DO, Belynda Veser, MD, Anu Nagar, MDDepartment of Psychiatry, Prisma Health,109 Physicians Drive, Greer, SC 29650.Ms. A. is an 84-year-old Hispanic female with a past psychiatric history of Mild Neurocognitive Disorder due to Frontotemporal lobar degeneration, major depressive disorder (MDD), and one episode of catatonia about six years prior to current presentation. She first presented to the emergency department (ED) for a motor vehicle collision that led to bruising and generalized tenderness. She had four ED visits over the next four weeks. At the fifth visit, she was hospitalized because of concerns of altered mental status (AMS), agitation, and hallucinations. She was noted to have a urinary tract infection (UTI) and bacteremia with positive blood cultures for Escherichia Coli. She was subsequently admitted to the inpatient medical service and the working diagnosis was delirium secondary to UTI/bacteremia, exacerbated by sleep deprivation. Imaging was performed to rule out intracranial abnormalities (e.g., subdural hematoma) following MVC.Psychiatry was consulted for the recent onset of altered mental status (AMS), increasing confusion, and hallucinations. Patient was assessed by consult liaison psychiatry service on day one of admission. Mental status exam was remarkable for the following pertinent positives: oriented to self only, tangential with loose associations, perseveration on her deceased husband, religiously preoccupied and responding to internal stimuli. She was able to recall 0 out of 3 objects in both immediate and delayed recall and having auditory and visual hallucinations. Patient consistently denied suicidal ideation and homicidal ideation. CT scan and MRI were negative and helped rule out acute intracranial abnormalities (e.g., subdural hematoma).Working diagnosis of acute hyperactive delirium secondary to UTI/bacteremia was managed with quetiapine, improving gradually over the subsequent eight days. Medical team managed UTI/bacteremia with 10 days of antibiotics as recommended by the Infectious Disease team and there was clinical evidence of resolved bacteremia and UTI. Quetiapine was titrated to maximum dosage of 100mg QAM, 100mg QPM and 200mg QHS with ongoing gradual improvement. However, she decompensated on day eight with new symptoms of catatonic-like stereotypical hand movements, repetition of words, and general sustained hyperactivity. The Bush Francis score (BFS) was 12. It was at this point that the daughter (a nurse) provided additional collateral history that there was a history of a similar episode of catatonia six years ago. A trial dosage of lorazepam 2mg IV was administered with subsequent improvement of BFS to 6. Over the next four days, lorazepam 1 mg IV was administered daily, and patient continued to improve. During this time, the dosage of Quetiapine was reduced, considering that delirium had improved, and Quetiapine could have been exacerbating the catatonia. However, titrating down of Quetiapine was done slowly to avoid abrupt discontinuation which could cause delirium to re-emerge. After receiving second dose of lorazepam, Montreal Cognitive Assessment (MoCA) score also dramatically improved from 6/30 to 22/30. She was subsequently discharged on day 13 to a nursing home where she was managed for 20 days and discharged home.Two learning objectives.• There is need to ask about history of catatonia in elderly patients as this may help heighten clinical suspicion especially in patients with delirium.• It is possible for a patient who presented with hyperactive delirium with clinical improvement and resolution of delirium to develop excited catatonia in a short time, so clinicians need to have a high index of suspicion especially among patients who have a history of catatonia. Given that hyperactive delirium alone responds excellent to antipsychotics while excited catatonia responds excellent to lorazepam IV, early diagnosis is of utmost important to adjust medications at the earliest time of noticing symptoms of excited catatonia.