Intermediate Care Facilities Research Articles

Stakeholders’ Perspectives on Rehabilitation Services in KwaZulu-Natal Province, South Africa: A Mixed-method Study

Background and Objectives: South Africa is committed to enhancing rehabilitation services by 2030 through the National Rehabilitation Policy and the United Nations Convention on the rights of persons with disabilities. However, limited research focuses on rehabilitation services in KwaZulu-Natal (KZN) Province, South Africa. This study aims to provide insights from stakeholders on rehabilitation services in KZN Province focused on infrastructure, referrals, human resources, and multidisciplinary practices. Methods: Using mixed methods, we conducted focus group discussions, interviews, and surveys involving 99 stakeholders, including rehabilitation practitioners, district and provincial managers, and social development representatives from eThekwini, AmaJuba, and King Cetshwayo in South Africa. Descriptive statistics and thematic analysis were used for quantitative and qualitative data. Results: Public institutions reported inadequate referral pathways (2.9 out of 5) compared to private institutions (3.4 out of 5). Acute rehabilitation referrals primarily targeted secondary or tertiary facilities. Disjointed pathways, a lack of protocols, delayed referrals due to various factors and insufficient staff were identified. Physiotherapists were disproportionally more prominent, while social workers, psychologists and bio-kineticists were scarce. Both public (93%) and private (73%) care exhibited high doctor-to-patient ratios. Rehabilitation service disciplines were limited and fragmented, especially in rural areas. Thirty-four respondents (81%) stated no designated rehabilitation services units in their respective institutions. Conclusion: Rehabilitation services, though present at all care levels in KZN, mostly begin at tertiary levels. Local-level rehabilitation is non-existent, with the public healthcare system relying on community rehabilitation workers. Referral pathways require standardization, especially at the local level. Enhancing primary healthcare’s rehabilitation focus by bolstering workforce recruitment can significantly improve multidisciplinary practices. Expanding intermediate care facility licenses can alleviate system strain on KZN’s public health sector.

The Association of Socio-Environmental Inequality and Outcomes Among Patients Undergoing Major Surgery

IntroductionEnvironmental hazards may influence health outcomes and be a driver of health inequalities. We sought to characterize the extent to which social–environmental inequalities were associated with surgical outcomes following a complex operation. MethodsIn this cross-sectional study, patients who underwent abdominal aortic aneurysm repair, coronary artery bypass grafting, colectomy, pneumonectomy, or pancreatectomy between 2016 and 2021 were identified from Medicare claims data. Patient data were linked with social–environmental data sourced from Centers for Disease Control and Agency for Toxic Substances and Disease Registry data based on county of residence. The Environmental Justice Index social–environmental ranking (SER) was used as a measure of environmental injustice. Multivariable regression analysis was performed to assess the relationship between SER and surgical outcomes. ResultsAmong 1,052,040 Medicare beneficiaries, 346,410 (32.9%) individuals lived in counties with low SER, while 357,564 (33.9%) lived in counties with high SER. Patients experiencing greater social–environmental injustice were less likely to achieve textbook outcome (odds ratio 0.95, 95% confidence interval 0.94-0.96, P < 0.001) and to be discharged to an intermediate care facility or home with a health agency (odds ratio 0.97, 95% confidence interval 0.96-0.98, P < 0.001). ConclusionsCumulative social and environmental inequalities, as captured by the Environmental Justice Index SER, were associated with postoperative outcomes among Medicare beneficiaries undergoing a range of surgical procedures. Policy makers should focus on environmental, as well as socioeconomic injustice to address preventable health disparities.

Trends in Diverticular Disease Hospitalizations and Racial Disparities in Outcomes Across the United States.

Objective This study evaluated trends and racial disparities in hospitalization, clinical outcomes, and resource utilization for diverticular disease (DD) between 2017 and 2020. Methods We performed a retrospective analysis using the NISdatabase from 1 January 2017 to 31 December2020to study hospitalizations for DD (CCSRcode: DIG013). Our primary outcomes were hospitalization rates, all-cause mortality, total charges, and length of stay. Secondary outcomes included in-hospital complicationsand discharge status. Outcomes were stratified by race and ethnicity (White, Black, Hispanic, Asian or Pacific Islanders and Native Americans). Data were weighted and adjusted for clustering, stratification, and other relevant factors. The normality of the continuous data distribution was confirmed usingKolmogorov-Smirnov, and descriptive statistics were used to summarizevariables. Demographic characteristics were compared usingχ² and Student's t-test, with significance set at P<0.05. We usedstepwise multivariable logistic regressionto estimateadjusted odds ratios for studyoutcomes by race and ethnicity, controlling for demographic and clinical factorsand correcting for multicollinearity. Missing data were treated with multiple imputations, trend analyses were performed using Jonckheere-Terpstra tests, and costs were adjusted for inflation using the GDPprice index. Analyses were conducted with Stata 17MP. Results A total of 1,266,539 hospitalizations for DD were included for analysis. Approximately953,220 (75.3%) were White patients and 313,319 (24.7) did not belong to the White race. Atotal of 747,868 (59%) were women compared to 518,671 (41%) men. Compared to patients who were not of the White race, White patients were younger(63.5 vs. 66.8 years; p<0.001). Hospitalizations for DD increased by 1.2% from 323,764 to 327,770 hospitalizations (2017-2019) and decreased by 11.8% from 327,770 to 289,245 admissions in 2020. Mortality rates were higher among White patients than in those not of the White race (16,205 (1.7%) vs 5,013 (1.6%)).However, no significant difference was observed in mortality odds between both sets of patients (aOR, 0.953; 95% CI 0.881-1.032; P=0.237).Mortality rates showed an uptrend over the study period (4,850 (1.5%) in 2017 to 5,630 (1.9%) in 2020; Ptrend<0.001).DD accounted for 7,016,718 hospital days, 2,102,749 procedures, and US$ 6.8 billion in hospital costs. Mean hospital costs increased from US$54,705 to US$72,564 over the study period (P<0.000). Patients who were not of the White race incurred higher mean hospital charges than White patients ($67,635 ± $6,700 vs $59,103 ± $3,850; P<0.001). Black race correlated with lower odds of bowel perforation, routine home discharge, and bowel resection (P<0.001). Conclusion During the study period, hospitalization and mortality rates and resource utilization for DD increased. Patients from other racesincurred higher hospital costs than White patients. White Americans were more likely to be discharged to skilled nursing, intermediate care, and other facilities. Additionally, White patients were less likely to develop bowel abscesses compared to patients who were not White. Compared to White American patients, Black patients had fewer DD hospitalizations complicated by bowel perforations or requiring bowel resections. In contrast, DD admissions among Hispanic patients were more likely to require bowel resections than those among White American patients.

Emergency general surgery in older adult patients: Factors associated with fragmented care

BackgroundCare fragmentation has been shown to lead to increased morbidity and mortality. We aimed to explore the factors related to care fragmentation after hospital discharge in geriatric emergency general surgery patients, as well as examine the association between care fragmentation and mortality. MethodsWe designed a retrospective study of the Nationwide Readmissions Database 2019. We included patients ≥65 years old admitted with an emergency general surgery diagnosis who were discharged alive from the index admission. The primary outcome was 90-day care fragmentation, defined as an unplanned readmission to a non-index hospital. Multivariable logistic regression was performed, adjusting for patient and hospital characteristics. ResultsA total of 447,027 older adult emergency general surgery patients were included; the main diagnostic category was colorectal (22.6%), and 78.2% of patients underwent non-operative management during the index hospitalization. By 90 days post-discharge, 189,622 (24.3%) patients had an unplanned readmission. Of those readmitted, 20.8% had care fragmentation. The median age of patients with care fragmentation was 76 years, and 53.2% were of female sex. Predictors of care fragmentation were living in rural counties (odds ratio 1.76, 95% confidence interval: 1.57–1.97), living in a low-income ZIP Code, discharge to intermediate care facility (odds ratio 1.28, 95% confidence interval: 1.22–1.33), initial non-operative management (odds ratio 1.17, 95% confidence interval: 1.12–1.23), leaving against medical advice (odds ratio 2.60, 95% confidence interval: 2.29–2.96), and discharge from private investor-owned hospitals (odds ratio 1.18, 95% confidence interval: 1.10–1.27). Care fragmentation was significantly associated with higher mortality. ConclusionThe burden of unplanned readmissions in older adult patients who survive an emergency general surgery admission is underestimated, and these patients frequently experience care fragmentation. Future directions should prioritize evaluating the impact of initiatives aimed at alleviating the incidence and complications of care fragmentation in geriatric emergency general surgery patients.

Hidden Dangers of Frailty: Higher Mortality, Complications and Costs in Acute Pancreatitis.

Frailty is a clinically recognizable state of increased vulnerability due to age-related decline in reserve and function across multiple physiologic systems that compromises the ability to cope with acute stress. As frailty is being identified as an important risk factor in outcomes of gastrointestinal pathologies, we aimed to assess outcomes in patients with acute pancreatitis within this cohort. We conducted a retrospective study using the Nationwide Inpatient Sample (NIS) database. ICD-10 codes were used to inquire for patients admitted with acute pancreatitis between September 2015 through 2017. ICD-10 codes corresponding to the Hospital Frailty Risk Score (HFRS) were used to divide the study sample into 2 cohorts: low risk (< 5 points) and intermediate or high risk (> 5 points). To calculate the points, we fitted a logistic regression model that included membership of the frail group as the binary dependent variable (frail vs. non-frail) and the set of ICD-10 codes as binary predictor variables (1 = present, 0 = absent for each code). To simplify the calculation and interpretation, we multiplied regression coefficients by five to create a points system, so that a certain number of points are awarded for each ICD-10 code and added together to create the final frailty risk score. Multivariate regression analysis was performed to find adjusted mortality. Out of a total of 1,267,744 patients admitted with acute pancreatitis, 728,953 (57.5%) were identified as intermediate and high risk (> 5 points) (study cohort) and 538,781 (42.5%) as low risk (< 5 points). The mean age in the study cohort was 64.8 ± 12.6 and that in the low-risk group was 58.6 ± 9.5. Most of the patients in both groups were males and Caucasians; Medicare was the predominant insurance provider. A majority of the admissions in both groups were in an urban teaching hospital and were emergency. (Table1). The primary outcome was in-hospital mortality which was significantly higher in the study cohort as compared to the low-risk group (4.3% vs. 2.5%, p < 0.0001). The age-adjusted Odds ratio of mortality was 1.72(95% CI (Confidence Interval) 1.65-1.80, p < 0.05). When compared between the two groups; median length of stay (6 vs. 4); hospitalization cost ($14,412 vs. $10,193), disposition to a skilled nursing facility (SNF) (17.1% vs. 8.6%) and need for home health care (HHC) was significantly higher in the study cohort. Complications like septicemia, septic shock, and acute kidney injury were also higher in the study group (Table2). Table1 Baseline demographics of the cohort Characteristics Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value N = 1,267,744 N = 728,953 (57.5%) N = 538,781 (42.5%) Age Mean years (Mean ± SD) 64.8 ± 12.6 58.6 ± 9.5 < 0.001 Gender < 0.001 Male 59.1% 52.3% Female 40.9% 47.7% *Missing-475 Age groups < 0.001 18-44 3.7% 14.3% 45-64 48% 52.9% 65-84 32.2% 28.7% ≥ 85 16.1% 4.1% Race < 0.001 Caucasians 67.4% 61.9% African Americans 9.6% 16.8% Others 23% 21.3% *Missing-10 Insurance type < 0.001 Medicare 40.9% 36.3% Medicaid 17.2% 24.3% Private 31.8% 27.9% Other 9.9% 11.4% *Missing-75 Active smoking 32.7% 37.9% 0.005 Biliary Stone 36.2% 16.7% < 0.001 Admission Type < 0.001 Emergent 93.7% 94.3% Elective 6.3% 5.7% *Missing-2880 Hospital ownership/control < 0.001 Rural 7.8% 10% Urban nonteaching 26.3% 26.6% Urban teaching 65.9% 63.4% Table2 Outcomes Outcomes Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value In-hospital mortality *Missing-920 4.3% 2.5% < .0001 1.72(1.65-1.80) < .0001 Length of stay, days (Median,IQR) 6(3-8) 4(2-6) < .0001 Total hospitalization cost, $ (Median,IQR) 14,412(8843-20,216) 10,193(6840-13,842) < .0001 In-Hospital Complications ARDS 0.4% 0.3% 0.08 Ventilator dependence respiratory failure 0.23% 0.29% 0.25 Septicemia 15.2% 9.6% < .0001 Septic Shock 6.1% 2.9% < .0001 AKI 24.8% 14.9% < .0001 Disposition < .0001 Discharge to home 58.9% 74.9% Transfer other: includes Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), and another type of facility 17.1% 8.6% Home health care 11.5% 8.1% Against medical advice (AMA) 1.6% 3.4% *Missing-920 CONCLUSION: Using frailty as a construct to identify those who are at greater risk for adverse outcomes, can help formulate interventions to target individualized reversible factors to improve outcomes in patients with acute pancreatitis. Future large-scale prospective studies are warranted to understand the dynamic and longitudinal relationship between pancreatitis and frailty.

Abstract 3823: Clinical outcomes of uveal melanoma patients in the emergency department

Abstract Purpose: Uveal melanoma is a rare ocular malignancy that has not been well characterized at a large scale. Specifically, uveal melanoma diagnosis and outcomes in the emergency department (ED) has not been characterized. Methods: The Nationwide Emergency Department Sample was queried from the last quarter of 2015 to 2019 to identify patients with a primary diagnosis of uveal melanoma. Multivariable logistic regression, with patient- and hospital-level characteristics as covariates, was used to identify factors associated with increased risk of inpatient admission. Results: From the last quarter of 2015 to 2019, there were 1,274 ED encounters with a primary diagnosis of uveal melanoma. Most patients were less than 11 years old (43.4%), male (51.1%), or a Medicaid beneficiary (37.8%), and most belonged to a family in the lowest income quartile (32.0%). The median age of these patients was 35 years (IQR: 2-64). Most patients presented to hospitals in the South (53.9%), with a Trauma Level I designation (51.4%), and most to a metropolitan teaching hospital (89.1%). The most common ED outcomes were same-day discharge (61.6%) and admission to the inpatient setting (31.2%). Patients presenting to Trauma Level I hospitals were most likely to be admitted (odds ratio [OR]=2.21; p=0.031). The factors that were most significantly associated with decreased odds of inpatient admission were: patients who were not charged for services (often due to charity) (OR=0.13; p=0.040), Medicaid beneficiaries (OR=0.27; p=0.031), and private insurance beneficiaries (OR=0.34; p=0.047). Among the admitted patients, patients can be discharged to home with self-care (76.2%) or with home-health care (14.9%) or can be transferred to an intermediate-care facility (8.1%). The mean hospital length of stay was 5.7±0.6 days. In-hospital mortality rate for admitted patients was very low (0.8%). Conclusion: Uveal melanoma patient outcomes are closely related to insurance status, indicating socioeconomic factors as a modulator of patient outcomes. Citation Format: Alice A. Beneke, Kamil Taneja, Lauren Ladehoff, Kevin Root, Eric Toloza. Clinical outcomes of uveal melanoma patients in the emergency department [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3823.

How the Family and Community Nurse Can Foster the Reduction of Improper Emergency Room Admissions and Promote Chronic Patient Care: Single-Center Observational Study - Asst GOM Niguarda

Background The incidence of improper access, with the consequent overcrowding of emergency room facilities, indirectly represents an indicator of evaluation of the local area's ability to take care of patients. In fact, overcrowding in the emergency room is often mainly attributable to patients requiring non-urgent or deferrable services, who access the emergency room due to the lack of hospital-territory integration, and for whom differential care could be envisaged in the setting of local care, as in the case of elderly patients suffering from chronic pathologies. The Family and Community Nurse (FaCN) is the professional figure of reference who ensures nursing care at different levels of complexity in collaboration with all the professionals present in the community in which he works, pursuing the interdisciplinary, health and social integration of services and professionals and placing the person at the center. Purpose From January 1st, 2023, a reporting process has been launched by the emergency room nursing staff for the chronic patient discharged to home and taken into care by the family and community nurse service. A retrospective single-center observational study was carried out on patients discharged from the Emergency Room of the ASST Grande Ospedale Metropolitano Niguarda. The data presented relates to the period 01.01.2023 - 30.09.2023. The purpose of the study is twofold: 1. Describe ways to ensure continuity of care between hospital and territory/primary care, identifying their level of complexity with the TRIAGE scale. 2. Identify the resources activated and interventions performed by the Territorial Team of Family and Community Nurses. Method Included in the study were chronic, home-discharged patients with chronic conditions who were domiciled or residing in the territory of afferent to ASST GOM Niguarda, referred by the nursing staff of the same emergency department and taken over by Family and Community Nurses (FaCNs). Exclusion Criteria affected chronic patients domiciled or residing in the territory of afferent to ASST Niguarda who refused to be taken in charge or admitted to hospital wards, intermediate care facilities, Health Care Residences for the Elderly. The triage scale is a first-level multidimensional assessment tool that aims at identifying complex social-health needs for the local area. It consists of eight items: morbidity, nutrition, alvus and diuresis, mobility, personal hygiene, mental status and behavior with whom he/she lives, and direct care. Four levels of severity are identified: absent or mild, moderate, severe, and very severe, with a score ranging from 0 to 2. The sum of the scores applied to the different domains constitutes the total score, which allows the complexity of patients to be stratified into three levels. The triage form is filled out by the Emergency Room nurse in the event of discharge of the patient and if the patient has a score between 3 and 10; the activation of the FaCN is envisaged through an email report made by the Caring Nurse to the Territorial FaCN service (pre-discharge phase). The FaCN takes charge of the patient and guarantees a series of interventions and care services in relation to the level of complexity of the needs expressed by the patient (post-discharge phase). Outcomes Patients discharged with chronic pathologies reported in the period indicated were 250, with an average age of 81.75 years (standard deviation 9.67). Most reports are included in the intermediate risk class between scores of 3 and 7, and the most represented age class is that of patients over 80 years old. In patients reported to the FaCN service, professionals reached the patient or his caregiver out for an initial approach, within 24 hours of discharge from the emergency room. The outcome of the reports made shows that in 48.8% of cases the FaCNs took steps to establish a connection between the FaCNs' service and the most competent territorial references closest to the patient and took care of them towards more appropriate services (home palliative care, mental health, etc.), while in 51.6% of cases the FaCN took charge of the patient directly, providing the appropriate care (medications, venous sampling, recording of vital parameters, health education interventions, therapeutic and engagement adherence, also through teleassistance). At the moment no other deaths have been recorded and in no case has the patient visited the Emergency Room again. Conclusion The activation of the FaCN for chronic patients discharged from the Emergency Room has made it possible to facilitate patient care, overcome the fragmentation of services, and guarantee continuity of care, both in cases in which the patient has been directly taken care of and assisted by the FaCNs, and in cases in which the patient has been directed/orientated towards other local services. Over time, it will be possible to reduce the volume of hospital care activities for fragile patients and inappropriate access to the Emergency Room, by strengthening the continuity of care, precisely guaranteed by the strategic value of the Family and Community Nurse.

Examining prevalence and predictors of pulmonary hypertension in adults with idiopathic pulmonary fibrosis: a population-based analysis in the United States.

Pulmonary hypertension (PH) often complicates idiopathic pulmonary fibrosis (IPF), a progressive parenchymal lung disease. We investigated predictors of PH in IPF hospitalizations in the United States. We identified IPF hospital- izations with or without PH using the National Inpatient Sample (2018) and relevant ICD-10-CM codes. We com- pared demographics, comorbidities, PH prevalence, and its multivariable predictors adjusted for confounders among patients with IPF. In 2018, 30,335 patients from 30,259,863 hospitalizations had IPF, of which 8,075 (26.6%) had PH. Black (41%), Hispanic (21.3%), and female (28.7%) patients had higher rates of PH compared to white patients (25%). The IPF-PH cohort was hospitalized more often in urban teaching (77.7% vs. 72.2%), Midwest, and West hospitals vs. non-PH cohort. Comorbidities including congestive heart failure (2.08 [1.81-2.39]), valvular disease (2.12 [1.74-2.58]), rheumatoid arthritis/collagen vascular disease (1.32 [1.08-1.61]) predicted higher odds of PH. The PH-IPF cohort was less often routinely discharged (35.4%) and more likely to be transferred to intermediate care facilities (22.6%) and home health care (27.1%) (P < 0.001). The PH-IPF group had higher rates of all-cause mortality (12.3% vs. 9.4%), cardiogenic shock (2.4% vs. 1%), dysrhythmia (37.6% vs. 29%), and cardiac arrest (2.7% vs. 1.5%) vs. non-PH cohort (all P < 0.001). Patients with PH-IPF also had longer hospital stays (9 vs. 8) and a higher median cost ($23,054 vs. $19,627, P < 0.001). Nearly 25% of IPF hospitalizations with PH were linked to higher mortality, extended stays, and costs, emphasizing the need to integrate demographic and comorbidity predictors into risk stratification for improved outcomes in patients with IPF-PH.

Engaging healthcare professionals in refining the target group of a new care type: The Acute Geriatric Community Hospital (AGCH) referral decision study

Background: The acute geriatric community hospital (AGCH) is an alternative to conventional hospitalisation of older adults. At the AGCH, patients receive acute medical specialist treatment in combination with early rehabilitation in an fitting environment by an interdisciplinary team of professionals. Ambiguity exists on the exact definition of the target group for the AGCH and the difference with the target groups for bed-based intermediate care and geriatric hospital care models.&#x0D; Objective: Limited guidelines and methods exist to refine the target group of new care model or (complex) health interventions. The aim of this study was to provide refined assessment criteria for the AGCH by using a target-group refinement procedure with case vignettes.&#x0D; Design: A design based research using qualitative research techniques. &#x0D; Setting: Two pioneer sites who have an AGCH in their region and seven pioneer sites who have the ambition to implement an AGCH in their region.&#x0D; Subjects: A total of 20 healthcare professionals (elderly care physicians, clinical geriatricians and other medical specialists, physician assistants, nurse specialists) participated in the AGCH target group refinement project, either active in hospitals (n=10) or intermediate care facilities (n=7) or skilled nursing facilities (n=3), and all involved in the implementation of an AGCH in their region.&#x0D; Methods: The developed target-group refinement procedure consisted of three phases. 1) Healthcare professionals from the pioneer sites were asked to submit case vignettes for a specific care type or an ambiguous boundary between the AGCH and other care models. These case vignettes were reviewed during 2) web-based vignette questionnaires and 3) two online working sessions. Both during phase 2 and 3, participants were asked to make a referral decision for the case vignettes they were presented with and to report their considerations during this process.&#x0D; &#x0D; Results: In total, 23 case vignettes were collected and reviewed by 18 healthcare professionals. Triage dilemmas were identified and discussed during online working sessions, following from which the AGCH assessment criteria were refined. We found that the final referral outcome is the result of an interplay of clinical and organisational triage factors.&#x0D; Conclusions: This target group refinement procedure enabled involving of a variety of healthcare professionals and was suitable to refine the AGCH assessment criteria. In a short time period, it provided us further insight into (1) the required changes to the AGCH assessment criteria; (2) the (ambiguous) boundaries between the AGCH and other care models, and (3) the considerations made by healthcare professionals during referral decision-making for older adults with an acute care need. We recommend to use this novel procedure as a tool for specifying the target group of (new) care models or healthcare interventions.&#x0D;

Antibody responses after BNT162b2 vaccination in Japanese geriatric intermediate care facilities

BackgroundTo evaluate antibody responses against the primary series of vaccination of severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2] vaccines in the staff and residents of Japanese geriatric intermediate care facilities. MethodsAll subjects (159 staff and 96 residents) received two doses of the BNT162b2 mRNA vaccine 3 weeks apart. Baseline data of subject were collected using a structured form. Serum samples were collected three times: before vaccination, 3 weeks after the first dose, and 4 weeks after the second dose, and anti-receptor binding domain of the spike protein of SARS-CoV-2 [anti-RBD] IgG was measured using two immunoassays. ResultsAfter the second dose, geometric mean titers [GMT] of anti-RBD with both the Abbott and Roche assay were significantly lower in residents than staff (2282 AU/mL vs. 8505 AU/mL, and 258 U/mL vs. 948 U/mL, respectively). Multivariate analysis of characteristics affecting antibody responses (≥1280 AU/mL for Abbott and > 210 U/mL for Roche) showed lower odds ratios [ORs] for older age (adjusted OR per 10 year increase [aOR] = 0.62, 95 % confidence interval [95 %CI]; 0.38–1.02), steroid usage (aOR = 0.09, 95 %CI; 0.01–0.60) and regular nonsteroidal anti-inflammatory drugs [NSAIDs] usage (aOR = 0.16, 95 %CI; 0.03–0.88). ConclusionsElderly people and steroid and NSAID users had lower antibody responses following the second vaccine dose.

Influence of Activated Protein C Resistance on Short-Term Hospital Outcomes Following Admission for Acute Ischemic Stroke in the United States

Introduction: Activated protein C (APC) plays a crucial role in breaking down factor Va and VIIIa, preventing excessive blood clotting. APC resistance occurs when protein C is unable to degrade these factors, leading to a higher risk of thrombosis. This condition can be either hereditary or acquired, with the most common cause being the factor V Leiden mutation. While previous studies have indicated that APC resistance increases the likelihood of acute ischemic stroke (AIS), their specific outcomes have not been extensively studied. Our research aims to bridge this gap via a national study. Methods: We used hospital records via the National Inpatient Sample (NIS) for our study. It consists of de-identified in-patient data, released on an annual basis by HCUP, AHRQ, and collaborating hospitals. Patients admitted with a primary diagnosis of AIS were recruited. We excluded all hospitalizations of ages &amp;lt;18 years. The impact of APCR status on outcomes and in-hospital complications such as acute kidney injury (AKI), myocardial infarction (MI), thrombolysis, mechanical thrombectomy (MT), vasopressor use, seizures, unfavorable discharge (discharge to another center such as short-term hospital, skilled nursing facility, intermediate care facility, and another type of facility) was studied using multivariable regression analysis, while adjusting for the impact of several potential patient and hospital characteristics. Results: Our selection criteria identified 2631890 admissions for AIS between 2016-2020, including 5910 (0.2%) patients also reporting a diagnosis of APCR (Table 1). In addition, APCR patients were younger (mean age 60.1 vs. 70.1 years, p&amp;lt;0.01) with a lower mean Charlson Comorbidity Index (CCI) score (3.50 vs. 3.87, p&amp;lt;0.01), and showed higher odds of a history of prior stroke (19.3% vs. 15.4%, aOR 1.482, 95% CI 1.387-1.584, p&amp;lt;0.01). While both groups were primarily covered by Medicare (65.0% in non-APCR group and 47.3% in APCR patients), a higher proportion of patients with APCR were also covered by private insurance (33.0% vs 19%, p&amp;lt;0.01). The APCR group also showed a higher prevalence of Whites (85.9% vs. 68.2%, p&amp;lt;0.01). Most cases in both cohorts were treated in Urban teaching centers. While higher prevalences of smoking(43.2% vs. 39.8%, p&amp;lt;0.01), obesity (20.3% vs. 14.5%, p&amp;lt;0.01), and drug abuse (4.4% vs. 2.8%, p&amp;lt;0.01) were seen in APCR patients, they also expressed fewer cases of cirrhosis (0.3% vs. 0.7%, p&amp;lt;0.01), diabetes (30.6% vs 39.2%, p&amp;lt;0.01), hypertension (51.9% vs 58.2%, p&amp;lt;0.01), chronic kidney disease (13.7% vs 18.3%, p&amp;lt;0.01), atrial fibrillation (18.8% vs 24.9%, p&amp;lt;0.01), and lipid disorder (53.8% vs 60.3%, p&amp;lt;0.01). After careful adjustments of confounders, APCR patients showed a higher use of mechanical thrombectomy (aOR 1.523, 95% CI 1.374-1.689, p&amp;lt;0.01) and vasopressor use (aOR 1.877, 95% CI 1.435-2.455, p&amp;lt;0.01) and also reported higher odds of seizures (aOR 1.413, 95% CI 1.265-1.578, p&amp;lt;0.01) and unfavorable discharge (aOR 1.065, 95% CI 1.006-1.128, p=0.03). However, lower odds of acute kidney injury (aOR 0.87, 95% CI 0.794-0.952, p&amp;lt;0.01) and death(aOR 0.708, 95% CI 0.597-0.838, p&amp;lt;0.01) were noted. No differences in events of MI (aOR 1.161, 95% CI 0.994-1.358, p=0.06) and thrombolysis (aOR 0.94, 95% CI 0.863-1.024, p=0.159) use were seen between the two groups. Conclusion: The study reported higher short-term outcomes, including increased use of mechanical thrombectomy and vasopressors and higher odds of seizures and unfavorable discharge in APCR patients with acute stroke. However, no similar increased odds of in-patient death, acute kidney injury, thrombolysis, and myocardial infarction were noted. While the impact of APCR on stroke recurrence has been highly debated in prior studies, our analysis provides a novel update showing an increased risk of subsequent stroke in patients with a history of stroke. Encouraging more extensive studies in a clinical setting, with larger groups of people and more extended observation periods, can provide a clearer understanding of the situation and thus improve their long-term outcomes.

The challenge of community care: evidence from the Family and Community Nurse model in Tuscany

Abstract Background The strengthening of primary care is one of the solutions proposed to increase the resilience of healthcare systems in Italy. Tuscany was the first region in Italy to use this model based on the results of a Regional Agency for Regional Health Services study. The aims is to describe the FCN model implementation across the three Local Health Authorities (LHAs) through the four C's framework of primary care. The regional resolution on FCN relabeled these milestones based on the FCN's role: transversality, proximity, continuity, customization. Methods A mixed method study was conducted with in-depth interviews of regional managers and surveys administered to middle nurse managers of the three LHAs. Results The interviews revealed a different state of progress of the FNC organisational model implementation, with one LHA pioneering, another LHA dealing with the implementation stage, and the third with a more recent, non-gradual implementation. The first two LHAs interpret the transversality as a strategic and the proximity as a vicinity feature. The other LHA sees the FNC as a tool for patient empowerment and proximity as service availability. The quantitative analysis shows a continuous take in charge in the pioneer LHA 54.8% (IC95% 46.8%-62.9%) with a lower temporary taking charge, 25.9% (IC95% 19.8%-31.9%), compared to the others, respectively 34.3% (IC95% 21.7%-47.0%) and 36.39% (IC95% 26.9%-45.8%). Places where the FCN provides care: the pioneering LHA as most of the home care and a 12% (IC95% 1.4%-22.5%) of intermediate care facilities use, the implementing LHA is totally home-based: 99% (IC95% 97.6%-100.3%) and with a continuous take in charge 48.6% (IC95% 34.5%-62.8), the recently implemented LHA a 6.8% (IC95% 2.2%-11.3%) of others. Conclusions Even in the same regional context, ruled by the same features’ model defining resolution, there have been different implementations and interpretations related to the different LHAs’ organizational histories. Key messages • In spite of the model’s implementations, the assistance provided doesn’t focus on single diseases but on people in the broader context of their family and community. • The FCN model is designed to strengthen the timely care of patients at home by coordinating activities and care interventions through a multidisciplinary team.

Impact of Treatment Modalities on Discharge Disposition in Blunt Splenic Injuries.

Management of blunt splenic trauma has evolved over several decades, trending towards nonoperative management and splenic artery embolization. Extensive research has been conducted regarding the management of blunt splenic injuries, but there is little data on the association of treatment modality with discharge disposition. This is an observational retrospective study conducted at a level-one trauma center with blunt splenic trauma patients of age ≥18 years between January 2010 and December 2021. The primary outcome of unfavorable discharge was defined as discharge to an acute care facility, intermediate care facility, long-term care facility, rehabilitation (inpatient) facility, or skilled nursing facility. Five hundred seventy-nine patients were included in the analysis, with 108 (18.7%) in the unfavorable group and 471 (81.3%) in the favorable group. Most patients were managed nonoperatively (69.3%), followed by splenectomy (25.0%) and embolization (5.7%). Due to the low number of embolizations performed during the study period, treatment modalities were grouped into two broad categories: intervention (embolization and splenectomies) and nonintervention. The treatment modality was found to have no significant impact on unfavorable discharge. Independent risk factors for unfavorable discharge included age >55 years, injury severity score (ISS) >15, hospital-acquired pneumonia, and in-hospital complications of sepsis. This study provides an understanding of specific demographic and clinical factors that may predispose blunt splenic injury trauma patients to an unfavorable discharge. Providers may apply these data to identify at-risk patients and subsequently adapt the care they provide in an effort to prevent the development of in-hospital pneumonia and sepsis.

Predictors of Facial Fractures in Trauma Patients: Retrospective Review at a Level I Trauma Center.

The incidence and causes of facial fractures differ between patients, but patterns arise within populations. These patterns vary by gender, age, and between countries. This study aims to determine variables to identify patients at risk for facial fractures in a United States trauma population. This is a single-center study of Trauma Registry data, inclusive of years July 1, 2016, to January 31, 2022. Inclusion criteria were based upon all trauma patients. Confirmation of a non-isolated facial fracture (dependent variable) was verified using ICD10 diagnosis codes. A logistic regression was performed in SPSS to ascertain the effects of predictor variables on the likelihood that a trauma patient will experience a facial fracture. 20377 patients were included in the analysis based upon the requirements specified in the methods section; 1575 (7%) had a positive facial fracture. The logistic regression model was statistically significant (N = 18507, P < .01). Significant risk factors for facial fracture identified included helicopter transport (OR = 1.35, P < .01) and increasing injury severity scores (OR = 1.07, P < .01). Modes of injury most likely to predict facial fracture included assault (OR = 6.62, P < .01), moped (OR = 2.02, P < .01), and motorcycle trauma (OR = 1.55, P < .01). The discharge disposition most likely among facial fracture patients included short-term general hospital (OR = 1.71, P < .01) and intermediate care facility (OR = 4.47, P < .01). Patients with traumatic injuries from assault, moped, and motorcycle accidents were more likely to present with facial fractures. These patients had more severe injuries, seen as increased ISS scores, higher likelihood of transport by helicopter, and the need for additional care after discharge.

Validation of a neurovascular comorbidity index for risk adjustment of comorbid conditions among ischemic stroke patients receiving reperfusion treatment

ObjectiveTo validate a comorbidity index specific to neurovascular patients and determine its performance relative to the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) among ischemic stroke patients receiving reperfusion treatments. MethodsPatients with ischemic stroke were identified in the National Inpatient Sample from Quarter 4 2015 to Quarter 4 2017. Ischemic stroke patients receiving reperfusion treatment, either with intravenous thrombolysis (IVT) only or mechanical thrombectomy (MT), were studied. The accuracy of the neurovascular comorbidities index (NCI) was compared to both the CCI and ECI in predicting in-hospital death and poor outcome (defined as death prior to discharge or discharge to a short-term hospital, a skilled nursing facility, an intermediate care facility, another long-term facility, or home health care). ResultsThere were 25,147 ischemic stroke patients who received reperfusion therapy with either IVT only or MT (with or without IVT). Approximately 6.9% of patients died during their hospitalization, and 65.4% of patients were classified as having a poor outcome based on their discharge disposition. The NCI outperformed both the CCI and ECI in predicting in-hospital death (IVT only, p<0.0001; MT, p<0.0001) and poor outcomes (IVT only, p<0.0001; MT, p<0.0001). ConclusionThe NCI is a more powerful predictor of in-hospital death and poor outcomes when compared to the CCI or ECI among ischemic stroke patients receiving reperfusion therapies. Further validation studies are needed to confirm the accuracy of the NCI among other neurovascular patient populations.

Patients with breast cancer and the threat of septicemia.

e18622 Background: A very dangerous complication that can occur in breast cancer patients is septicemia. However, there are not many large scale studies that have demonstrated patient and hospital factors associated with higher risk of this complication in breast cancer patients. Methods: We utilized the 2006-2012 Nationwide Emergency Department Sample to identify breast cancer patients that presented to the emergency department (ED) with a primary diagnosis of septicemia. A multivariate logistic regression was used to identify characteristics that were significantly associated with a higher chance of septicemia. A p-value less than 0.05 was considered significant. Results: Between 2006 and 2012, 2,160,701 breast cancer patients presented to the ED. Out of these patients, 39,164 (1.8%) presented to the ED with a primary diagnosis of septicemia. Most patients were at least 80 years old (61.5%), female (98.9%), Medicare beneficiaries (73.8%), of the highest income quartile (28.6%), living in the South (34.3%), presented to non-trauma hospitals (51.5%), and presented to metropolitan non-teaching hospitals (46.0%). Factors associated with the highest risk of septicemia in breast cancer patients are the following: Medicaid patients (odds ratio (OR): 2.0, 95% Confidence Interval (CI): 1.6-2.6, p &lt; 0.001), Medicare patients (OR: 2.0, 95% CI: 1.6-2.5, p &lt; 0.001), private insurance patients (OR: 1.7, 95% CI: 1.4-2.1, p &lt; 0.001), living in the West (OR: 1.5, 95% CI: 1.3-1.7, p &lt; 0.001), living in the Northeast (OR: 1.3, 95% CI: 1.1-1.5, p &lt; 0.001), presenting to a metropolitan non-teaching hospital (OR: 1.2, 95% CI: 1.1-1.4, p = 0.03), and presenting to a metropolitan teaching hospital (OR: 1.3, 95% CI: 1.1-1.5, p = 0.003). Almost all breast cancer patients with septicemia were admitted (97.6%), discharged the same day (1.0%), or transferred to a short-term hospital (0.7%). Amongst patients that were admitted, most patients were discharged (34.4%), transferred to a skilled nursing facility or intermediate care facility (29.8%), or died (16.2%). Risk factors associated with increased risk of dying in septicemia patients are the following: living in the Northeast (OR: 1.4, 95% CI: 1.2-1.8, p = 0.001), presenting to a metropolitan teaching hospital (OR: 1.3, 95% CI: 1.0-1.7, p = 0.046), and living in the South (OR: 1.2, 95% CI: 1.0-1.5, p = 0.045). Conclusions: After correcting for patient and hospital characteristics, a patient’s insurance status, the hospital’s region, and the hospital’s teaching status are intimately related to a breast cancer patient's risk to develop septicemia. Furthermore, hospital region and teaching status are also associated with a breast cancer patient’s risk of dying from septicemia. This suggests that a patient’s access to resources is critical for their risk of developing cancer-related complications.

Elucidating the connection between pneumonia and melanoma: Risk factors and outcomes for patients with melanoma.

e21561 Background: Pneumonia is a common cause of morbidity and mortality in patients with melanoma and leads to many ED visits per year in the US. However, there is no national-level study that has assessed factors that increase risk for melanoma patients to present to the ED with a primary diagnosis of pneumonia. Methods: We utilized the 2006-2012 Nationwide Emergency Department Sample to identify melanoma patients that presented to the emergency department (ED) with a primary diagnosis of pneumonia. A multivariate logistic regression was used to identify characteristics that were significantly associated with a higher chance of pneumonia. A p-value less than 0.05 was considered significant. Results: Between 2006 and 2012, 239,956 melanoma patients presented to the ED. Amongst these patients, 3.1% presented to the ED with a primary diagnosis of pneumonia. The majority of patients were at least 80 years old (64.3%), male (61.5%), Medicare beneficiaries (73.1%), of the highest income quartile (28.7%), living in the South (35.7%), presented to non-trauma hospitals (53.1%), and presented to metropolitan non-teaching hospitals (44.9%). Factors associated with the highest risk of pneumonia in melanoma patients are the following: Medicaid patients (odds ratio (OR): 2.5, 95% Confidence Interval (CI): 1.4-4.4, p=0.003), Medicare patients (OR: 2.3, 95% CI: 1.4-3.0, p=0.002), private insurance patients (OR: 2.1, 95% CI: 1.3-3.5, p=0.005), non-metropolitan teaching hospitals (OR: 1.6, 95% CI: 1.3-1.9, p&lt;0.001), living in the Northeast (OR: 1.3, 95% CI: 1.3-3.5, p=0.005), being male (OR: 1.3, 95% CI: 1.1-1.4,p&lt;0.001) a high Charlson Comorbidity Index (OR: 1.3, 95% CI: 1.2-1.3, p&lt;0.001). The majority of patients were either admitted (86.4%) or discharged home the same day (11.1%). Amongst the patients that were admitted, most patients were discharged (59.0%), transferred to a skilled nursing facility or intermediate care facility (19.2%), or given home health care (15.8%). Only 4.0% of admitted patients died in the hospital. Conclusions: A melanoma patient’s risk for developing pneumonia is depending on insurance status, the region of their hospital, their biological sex, and the presence of comorbidities. Clinicians should be aware of these risk factors to minimize the risk of pneumonia occurring in this at-risk population.

94 A Review of the Utility of the Readmission Risk Scale in Hospitalized Burn Injured Patients

Abstract Introduction The burden of wound care post-hospitalization is often overwhelming, not only for patients and their families but also for home health nurses and intermediate care facilities. Inadequate wound care following hospital discharge can lead to wound deterioration and hospital readmission. These readmissions impact the patient, as well as healthcare institutions, physicians, payor sources, and policy makers. Readmission Risk Scales (RSS) exist but typically focus on those patients with chronic illness. Our hospital’s RRS consists of 16 items: patient without a primary care physician (PCP), active problem list &amp;gt; 2, past medical history &amp;gt; 2, age ≥ 50, lives alone, high fall risk, length of stay &amp;gt; 10 days, mental health disorder, diabetes, heart failure, COPD, alcohol abuse, drug use, uninsured/Medicaid, &amp;gt; 2 ED visits in previous 6 months and prior readmission within 30 days. The purpose of this study was to evaluate the fit of our current RSS for burn patients and identify other variables that may be predictive of readmission in burn patients. Methods This was a retrospective chart review of burn patients admitted over a 1-year period. Primary outcome measures were RSS scores, individual RSS variables, social determinants of health and incidence of readmission within 30 days of discharge. Readmitted patients were compared to those who did not require readmission. Descriptive statistics were calculated, and bivariate and multivariable logistic regressions (forward LR) were used to identify variables that contributed uniquely to readmission. Results A total of 600 burn patients were admitted over the study period of which 449 met inclusion/exclusion criteria. Thirty-two (7%) of these patients were readmitted within 30 days of their initial hospital discharge. In bivariate analyses, only 4 of the current RRS variables were statistically significant predictors of readmission within 30 days, patient without a PCP (p=.019), active problem list &amp;gt; 2 (p&amp;lt; .001), mental health disorder (p=.004) and drug use (p&amp;lt; .00004). However, when these variables were tested simultaneously in one predictive equation, only drug use remained significantly predictive. The total RSS score accounted for only 1.1% of the variance in readmission within 30 days. Conclusions The national readmission rate is 12%, and our overall rate was substantially below this. However, our current Readmission Risk Scale is not predictive in identifying those patients at risk for being readmitted within 30 days of discharge. Further investigation is warranted to identify additional variables to identify at risk patients. Applicability of Research to Practice A valid readmission risk assessment tool, would be beneficial to identify patients who are at risk for readmission and enhancing discharge planning.

Gender differences in the discharge outcomes post-TMVR among us patients 65 years and above: a review of 4,678 patients from the national inpatient sample

Abstract Funding Acknowledgements Type of funding sources: None. Background Though the Transcatheter mitral valve repair (TMVR) procedure has been shown to be beneficial among patients with moderate to severe mitral regurgitation, the effect of sex on the discharge outcomes post-TMVR remains unclear. Purpose We evaluated the gender differences in the outcomes, including death, next-day discharge, and discharge disposition among patients who underwent TMVR in the United States National Inpatient Sample (NIS) Database. We hypothesized that there would be no difference in the outcome of TMVR by gender in this study population. Methods Using the United States NIS Database 2016 – 2019, we identified all patients aged ≥ 65 years with a first listed ICD-10 procedure code of 02UG3JZ corresponding to the TMVR procedure. We classified patients with length of stay (LOS) ≤ 1 day as next day discharge (NDD) and LOS &amp;gt;1 day as non-NDD. Discharge disposition was classified as home/short-term facility, long term facility, or death. Home/short-term facility was defined as patients who were discharged to home, to a short-term hospital, against medical advice, alive with an unknown destination, to home health care, or transferred to court/law enforcement. Disposition was defined as long-term facility if patients were discharged to a skilled nursing facility or intermediate care facility, or another type of facility. Multivariable logistic regression was used to estimate the odds of death and non-NDD, comparing all male patients who had a TMVR to all female patients who underwent TMVR adjusting for age, race, sex, Charlson Co-morbidity Index (CCI) score, median household income, primary insurance, hospital region, teaching status of the hospital and hospital bed size. Results Our study included 4,678 patients (mean age ± SD = 80.4 ± 6.8) who had TMVR between 2016 to 2019. In our study population, 47.5% were females (mean age ± SD = 80.7 ± 6.7) and 52.5% (mean age ± SD = 80.0 ± 6.8) were males. The mean CCI score was lower in females compared to men (mean CCI score ± SD = 2.8 ± 1.9 vs. 3.2 ± 2.0; p&amp;lt;0.0001). Of the seventy-four (74) patients that died, 42 (56.8%) were female and 32 (43.2%) were male (p=0.10). Males were more likely to be discharged to a home/short-term facility than females (53.8% vs. 46.2%; p&amp;lt;0.0001), while females were more likely to be discharged to a long-term facility than males (57.3% vs. 42.7%; p&amp;lt;0.0001). Males were more likely to be discharged within the next day than females (56.1% vs. 43.9%; p&amp;lt;0.0001). Compared to males, females had a higher odds of death (odds ratio (OR), 1.71 [95% CI, 1.03-2.83]; p=0.04) post-TMVR. Females also had higher odds of non-NDD compared to their male counterparts (odds ratio (OR), 1.42 [95% CI, 1.25-1.60]; p&amp;lt;0.0001) post-TMVR. Conclusion Among patients aged 65 years and above who had a TMVR procedure, females were more likely to be discharged to a long-term facility and had higher odds of death and non-next-day discharge than males.

Understanding risk for early dislocation resulting in reoperation within 90 days of reverse total shoulder arthroplasty: extreme rare event detection through cost-sensitive machine learning

Reliable prediction of postoperative dislocation after reverse total shoulder arthroplasty (RSA) would inform patient counseling as well as surgical and postoperative decision making. Understanding interactions between multiple risk factors is important to identify those patients most at risk of this rare but costly complication. To better understand these interactions, a game theory-based approach was undertaken to develop machine learning models capable of predicting dislocation-related 90-day readmission following RSA. A retrospective review of the Nationwide Readmissions Database was performed to identify patients who underwent RSA between 2016 and 2018 with a subsequent readmission for prosthetic dislocation. Of the 74,697 index procedures included in the data set, 740 (1%) experienced a dislocation resulting in hospital readmission within 90 days. Five machine learning algorithms were evaluated for their ability to predict dislocation leading to hospital readmission within 90 days of RSA. Shapley additive explanation (SHAP) values were calculated for the top-performing models to quantify the importance of features and understand variable interaction effects, with hierarchical clustering used to identify cohorts of patients with similar risk factor combinations. Of the 5 models evaluated, the extreme gradient boosting algorithm was the most reliable in predicting dislocation (C statistic = 0.71, F2 score = 0.07, recall = 0.84, Brier score = 0.21). SHAP value analysis revealed multifactorial explanations for dislocation risk, with presence of a preoperative humerus fracture; disposition involving discharge or transfer to a skilled nursing facility, intermediate care facility, or other nonroutine facility; and Medicaid as the expected primary payer resulting in strong, positive, and unidirectional effects on increasing dislocation risk. In contrast, factors such as comorbidity burden, index procedure complexity and duration, age, sex, and presence or absence of preoperative glenohumeral osteoarthritis displayed bidirectional influences on risk, indicating potential protective effects for these variables and opportunities for risk mitigation. Hierarchical clustering using SHAP values identified patients with similar risk factor combinations. Machine learning can reliably predict patients at risk for postoperative dislocation resulting in hospital readmission within 90 days of RSA. Although individual risk for dislocation varies significantly based on unique combinations of patient characteristics, SHAP analysis revealed a particularly at-risk cohort consisting of young, male patients with high comorbidity burdens who are indicated for RSA after a humerus fracture. These patients may require additional modifications in postoperative activity, physical therapy, and counseling on risk-reducing measures to prevent early dislocation after RSA.