Intermountain Healthcare Hospitals Research Articles

Associations between blood donor sex and age, and outcomes of transfused newborn infants.

It is controversial whether the sex or age of red blood cell (RBC) donors affects mortality or morbidities of transfused newborn infants. We assessed these issues using a multi-year, multi-hospital database linking specific outcomes of neonatal transfusion recipients with RBC donor sex and age. We performed retrospective analyses of all neonates receiving ≥ one RBC transfusion during a 12-year period in all Intermountain Healthcare hospitals, matching mortality and specific morbidities of each transfusion recipient with the sex and age of each donor. There were 6396 RBC transfusions administered to 2086 infants in 15 hospitals. A total of 825 infants were transfused exclusively with RBC from female donors, 935 infants were transfused exclusively with RBC from male donors, and 326 infants were transfused with RBC from both female and male donors. No differences in baseline characteristics were identified among the three groups. Infants who received blood from both male and female donors had more RBC transfusions (5.3 ± 2.9 transfusions if received both male and female donor blood vs. 2.6 ± 2.2 if received blood from only one sex, mean ± SD, p < .001). We identified no significant differences in mortality or morbidities associated with the sex or the age of blood donors. Similarly, an analysis of matched vs. mismatched donor/recipient sex revealed no associations with death or neonatal morbidities. These data support the practice of transfusing newborn infants with RBC obtained from donors of either sex and regardless of donor age.

Frequency and Outcomes of Patients Presenting with Non-ST Elevation Myocardial Infarction (NSTEMI) without Standard Modifiable Risk Factors: A US Healthcare Experience.

Patients with ST-elevation myocardial infarction (STEMI), but without standard modifiable risk factors (SMuRF-less), are surprisingly common and appear to have a worse, or at best similar, short-term prognosis. However, relatively little attention has been paid to the prevalence and prognosis of SMuRF-less patients with non-STEMI (NSTEMI). The aim of our study was to identify the proportion and outcomes of SMuRF-less NSTEMI patients in a large US healthcare population. Patients with NSTEMI between 2001-2021 presenting to Intermountain Healthcare hospitals and catheterization laboratories were included. SMuRF-less status was defined as no clinical diagnosis of, or treatment for, hypertension, hyperlipidemia, diabetes, and smoking. Outcomes were assessed at 60 days and long-term for major adverse cardiovascular events (MACE: death, myocardial infarction, and heart failure hospitalization). Multivariable Cox proportional hazard regression was used to determine MACE hazard ratios (HR) for SMuRF-less versus patients with SMuRF. NSTEMI patients totaled 8196, of which 1458 (17.8%) were SMuRF-less. SMuRF-less patients were younger, more frequently male, had fewer comorbidities, and were slightly less likely to have revascularization. For SMuRF-less patients, 60-day MACE outcomes were lower (adj HR = 0.55, p < 0.0001), and this persisted for long-term MACE outcomes (adj HR = 0.64, p < 0.0001) and for each of its components. In this large US healthcare population, SMuRF-less NSTEMI presentation, as with STEMI presentation, was found to be common (17.8%). However, unlike STEMI reports, short- and long-term outcomes were better for SMuRF-less patients. Further studies to increase understanding of risk factors and preventive measures for NSTEMI in SMuRF-less patients are indicated.

Economics and outcomes of sotalol in-patient dosing approaches in patients with atrial fibrillation.

IntroductionThere exists variability in the administration of in‐patient sotalol therapy for symptomatic atrial fibrillation (AF). The impact of this variability on patient in‐hospital and 30‐day posthospitalization costs and outcomes is not known. Also, the cost impact of intravenous sotalol, which can accelerate drug loading to therapeutic levels, is unknown.MethodsOne hundred and thirty‐three AF patients admitted for oral sotalol initiation at an Intermountain Healthcare Hospital from January 2017 to December 2018 were included. Patient and dosing characteristics were described descriptively and the impact of dosing schedule was correlated with daily hospital costs/clinical outcomes during the index hospitalization and for 30 days. The Centers for Medicare and Medicaid Services reimbursement for 3‐day sotalol initiation is $9263.51. Projections of cost savings were made considering a 1‐day load using intravenous sotalol that costs $2500.00 to administer.ResultsThe average age was 70.3 ± 12.3 years and 60.2% were male with comorbidities of hypertension (83%), diabetes (36%), and coronary artery disease (53%). The mean ejection fraction was 59.9 ± 7.8% and the median corrected QT interval was 453.7 ± 37.6 ms before sotalol dosing. No ventricular arrhythmias developed, but bradycardia (<60 bpm) was observed in 37.6% of patients. The average length of stay was 3.9 ± 4.6 (median: 2.2) days. Postdischarge outcomes and rehospitalization rates stratified by length of stay were similar. The cost per day was estimated at $2931.55 (1. $2931.55, 2. $5863.10, 3. $8794.65, 4. $11 726.20).ConclusionsIn‐patient oral sotalol dosing is markedly variable and results in the potential of both cost gain and loss to a hospital. In consideration of estimated costs, there is the potential for $871.55 cost savings compared to a 2‐day oral load and $3803.10 compared to a 3‐day oral load.

A Novel Program to Provide Drug Recovery Assistance and Outpatient Parenteral Antibiotic Therapy in People Who Inject Drugs.

BackgroundSafe hospital discharge on parenteral antibiotic therapy is challenging for people who inject drugs (PWID) admitted with serious bacterial infections (SBI). We describe a Comprehensive Care of Drug Addiction and Infection (CCDAI) program involving a partnership between Intermountain Healthcare hospitals and a detoxification facility (DF) to provide simultaneous drug recovery assistance and parenteral antibiotic therapy (DRA-OPAT).MethodsThe CCDAI program was evaluated using a pre-/poststudy design. We compared outcomes in PWID hospitalized with SBI during a 1-year postimplementation period (2018) with similar patients from a historical control period (2017), identified by propensity modeling and manual review.ResultsEighty-seven patients were candidates for the CCDAI program in the implementation period. Thirty-five participants (40.2%) enrolled in DRA-OPAT and discharged to the DF; 16 (45.7%) completed the full outpatient parenteral antibiotic therapy (OPAT) duration. Fifty-one patients with similar characteristics were identified as a preimplementation control group. Median length of stay (LOS) was reduced from 22.9 days (interquartile interval [IQI], 9.8–42.7) to 10.6 days (IQI, 6–17.4) after program implementation (P < .0001). Total median cost decreased from $39 220.90 (IQI, $23 300.71–$82 506.66) preimplementation to $27 592.39 (IQI, $18 509.45–$48 369.11) postimplementation (P < .0001). Ninety-day readmission rates were similar (23.5% vs 24.1%; P = .8). At 1-year follow-up, all-cause mortality was 7.1% in the preimplementation group versus 1.2% postimplementation (P = .06).ConclusionsPartnerships between hospitals and community resources hold promise for providing resource-efficient OPAT and drug recovery assistance. We observed significant reductions in LOS and cost without increases in readmission rates; 1-year mortality may have been improved. Further study is needed to optimize benefits of the program.

Neonatal Reference Intervals for the Complete Blood Count Parameters MicroR and HYPO-He: Sensitivity Beyond the Red Cell Indices for Identifying Microcytic and Hypochromic Disorders

To create neonatal reference intervals for the MicroR and HYPO-He complete blood count (CBC) parameters and to test whether these parameters are sensitive early markers of disease at early stages of microcytic/hypochromic disorders while the CBC indices are still normal. We retrospectively collected the CBC parameters MicroR and HYPO-He, along with the standard CBC parameters, from infants aged 0-90days at Intermountain Healthcare hospitals using Sysmex hematology analyzers. We created reference intervals for these parameters by excluding values from neonates with proven microcytic disorders (ie, iron deficiency or alpha thalassemia) from the dataset. From >11 000 CBCs analyzed, we created reference intervals for MicroR and HYPO-He in neonates aged 0-90days. The upper intervals are considerably higher in neonates than in adults, validating increased anisocytosis and polychromasia among neonates. Overall, 52% of neonates with iron deficiency (defined by reticulocyte hemoglobin equivalent <25 pg) had a MicroR >90% upper interval (relative risk, 4.14; 95% CI, 3.80-4.53; P<.001), and 68% had an HYPO-He >90% upper interval (relative risk, 6.64; 95% CI, 6.03-7.32; P<.001). These 2 new parameters were more sensitive than the red blood cell (RBC) indices (P<.001) in identifying 24 neonates with iron deficiency at birth. We created neonatal reference intervals for MicroR and HYPO-He. Although Sysmex currently designates these as research use only in the US, they can be measured as part of a neonate's CBC with no additional phlebotomy volume or run time and can identify microcytic and hypochromic disorders even when the RBC indices are normal.

A New Hour-Specific Serum Bilirubin Nomogram for Neonates ≥35 Weeks of Gestation

To develop a statistically rigorous, hour-specific bilirubin nomogram for newborns based on a very large data set; and use it prospectively as a replacement for the 1999 Bhutani nomogram. This was a retrospective analysis of first total serum bilirubin (TSB) measurements from 15years of universal bilirubin screening during birth hospitalizations at 20 Intermountain Healthcare hospitals. Hour-specific TSB values were assembled into a nomogram by percentile, and subgroups were compared. The information obtained included robust data in the first 12hours after birth (which was not included in the 1999 nomogram), general agreement with the 1999 nomogram for values in the first 60hours, but higher 75th and 95th percentile TSB values thereafter in the new version, no difference in TSB between male and female infants, higher TSB values among earlier gestation neonates (350/7-366/7weeks vs ≥37weeks, P<.0001), and lower TSB values in neonates of Black race (P<.0001) and higher values in neonates of Asian race (P<.001). An updated and more informative Bhutani neonatal bilirubin nomogram, based on 140 times the number of subjects included the 1999 version, is now in place in our health care system.

Abstract 16802: Economics and Outcomes of Sotalol and Dofetilide In-Patient Dosing Approaches in Patients With Atrial Fibrillation

Background: Inpatient initiation of sotalol (STL) and dofetilide (DFL) for patients with symptomatic atrial fibrillation (AF) can be variable, more so for STL. Objective: Define the impact of inpatient initiation of STL and DFL approaches on patient in-hospital costs and outcomes. Methods: AF patients that were admitted for STL (n=133) or DFL (n=38) initiation at an Intermountain Healthcare Hospital in 2018 were included to provide contemporary insight. Patient and dosing characteristics were described descriptively, and the impact of dosing schedule was correlated with daily hospital costs and outcomes. The CMS reimbursement for 3-day initiation of STL or DFL is $9,263.51. Results: The average age of the complete population was 69.7±11.7 years and 64.3% were male. Baseline risk factors were similar between groups. Mean ejection fraction was 59.2±8.9% and median QTc was 455.7±38.5 ms before STL dosing and 453.7±37.6 before DFL dosing. The average length of stay was 3.7±4.2 days and was shorter for DFL (3.0±2.0) compared to the STL (3.9±4.6). Within the DFL group, most received 5-6 doses, whereas STL dosing frequency was variable (Figure A). DFL discharge dose in 22 (57%) was 500 mcg BID and 125 mcg BID in 8 (21%). STL dose was 80 mg BID in 96 (72.1%) and 40 mg BID in 29 (21.8%). Total costs per hospitalization and per day were higher for STL compared to DFL (Figure B). QTc prolongation &gt;500 ms was more common with DFL versus STL and other long-term outcomes were similar (Figure C). A 24 load of IV sotalol result in a cost savings of $871.55 vs. a 2-day load and $3,803.10 vs. a 3-day oral load. Conclusion: Routine contemporary inpatient STL dosing is markedly variable and results in the potential of both cost gain and loss to a hospital. Under dosing of STL is also common and may negatively impact long-term outcomes.

Blood Eosinophil Count and Hospital Readmission in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

PurposeThis retrospective, observational cohort study investigated the association of blood eosinophil counts within 1 week of hospitalization for acute exacerbation of COPD (AECOPD) with subsequent risk of all-cause and COPD-related readmission from a large integrated health system.Patients and MethodsElectronic medical records were extracted for index hospitalization for AECOPD at all Intermountain Healthcare hospitals. The primary outcome was the relationship of blood eosinophil count to 30-day all-cause readmission; secondary outcomes were 60-day, 90-day, and 12-month all-cause readmission, COPD-related readmission, and empiric derivation of the eosinophil count with the highest area under the curve (AUC) for predicting 30-day all-cause readmission.ResultsOf 2445 included patients, 1935 (79%) had a blood eosinophil count <300 cells/µL and 510 (21%) had a count ≥300 cells/µL. Using a 300-cells/μL threshold, there was no significant difference between high and low eosinophil groups in 30-day (odds ratio [OR]=1.05, 95% confidence interval [CI]=0.75–1.47) or 60-day (OR=1.15, 95% CI=0.88–1.51) all-cause readmissions. However, patients with greater (versus lesser) eosinophil counts had increased 90-day and 12-month all-cause readmissions (OR=1.35, 95% CI=1.06–1.72, and OR=1.32, 95% CI=1.07–1.62). COPD-related readmission rates were significantly greater for patients with greater (versus lesser) eosinophil counts at 30, 60, and 90 days and 12 months (OR range=1.52–1.97). A total of 70 cells/µL had the most discriminatory power to predict 30-day all-cause readmission (highest AUC).ConclusionEosinophil counts in patients with COPD were not associated with a difference in 30-day all-cause readmissions. However, greater eosinophil counts were associated with increased risk of all-cause readmission at 90 days and 12 months and COPD-related readmission at 30, 60, and 90 days and 12 months. Patients with eosinophils <70 cells/μL had the lowest risk for 30-day all-cause readmission. Blood eosinophils in patients hospitalized with AECOPD may be a useful biomarker for the risk of hospital readmission.

Antibiotic Exposure and Risk for Hospital-Associated Clostridioides difficile Infection.

Clostridioides difficile infection (CDI) is a health care-associated infection associated with significant morbidity and cost, with highly varied risk across populations. More effective, risk-based prevention strategies are needed. Here, we investigate risk factors for hospital-associated CDI in a large integrated health system. In a retrospective cohort of all adult admissions to 21 Intermountain Healthcare hospitals from 2006 to 2012, we identified all symptomatic (i) hospital-onset and (ii) health care-facility-associated, community-onset CDI. We then evaluated the risk associated with antibiotic exposure, including that of specific agents, using multivariable logistic regression. A total of 2,356 cases of CDI among 506,068 admissions were identified (incidence, 46.6 per 10,000). Prior antibiotic use was the dominant risk factor, where for every antibiotic day of therapy prior to the index admission, the odds of subsequent CDI increased by 12.8% (95% confidence interval [CI], 12.2 to 13.4%; P < 0.0001). This was a much stronger association than was inpatient antibiotic exposure (odds ratio [OR], 1.007 [95% CI, 1.005 to 1.009]; P < 0.0001). The highest-risk antibiotics included second-generation and later cephalosporins (especially oral), carbapenems, fluoroquinolones, and clindamycin, while doxycycline and daptomycin were associated with a lower CDI risk. We concluded that cumulative antibiotic exposure prior to admission is the greatest contributor to the risk of subsequent CDI. Most classes of antibiotics carry some risk, which varies by drug and route. This information may be useful for antimicrobial stewardship efforts.

1957. Impact of β-Lactam Antibiotic Allergy on Antimicrobial Use, Clinical Outcomes, and Costs for Hospitalized Children

BackgroundMost β-lactam antibiotic allergies (BLA) are incorrectly diagnosed and could be de-labeled. Adult patients with BLA are more likely to receive broader-spectrum antimicrobials and experience worse health outcomes than nonallergic patients. Similar studies on the impact of BLA on antimicrobial use and clinical outcomes are limited in pediatrics. Our objective was to compare antimicrobial use, and clinical and economic outcomes between hospitalized children with and without BLA.MethodsThis was a retrospective cohort of pediatric patients hospitalized at an Intermountain Healthcare (IH) hospital from 2007 to 2017. IH has 22 hospitals including one children’s hospital. Patients aged 30 days-17 years who received ≥1 dose of an antimicrobial during hospitalization were included. The exposure variable was the presence of BLA (penicillins or cephalosporins) in the allergy field of the medical record. Patients with BLA were matched to nonallergic controls on age, sex, race, clinical service line, admission date, children’s hospital or other hospital, and co-morbid conditions. We used multivariable log-transformed-linear and logistic regression models to compare patients with BLA to controls in terms of antibiotic selection and total antimicrobial days, antimicrobial cost, length-of-stay (LOS) and 30-day readmission. For antibiotic selection we examined the odds of receiving the following broader-spectrum agents individually and in composite: vancomycin, fluoroquinolones, clindamycin, carbapenems, and macrolides.Results39,785 patients were identified including 2897 (7%) with BLA. The prevalence of BLA increased with age (Figure 1). 2459 (85%) patients with BLA were matched to a control. Patients with BLA had higher odds of receiving broader-spectrum antibiotics (OR 2.35, 95% CI: 2.07–2.67) and had greater antimicrobial costs (1.21-fold increase, 95% CI: 1.08–1.35) than nonallergic patients (Figure 2). There were no differences in LOS, total antimicrobial days, or 30-day readmission (Figure 2).ConclusionPediatric patients with BLA are more likely to receive broader-spectrum antibiotics and incur higher antimicrobial costs than matched controls. De-labeling interventions could reduce unnecessary exposure to these agents and lower costs. Disclosures All Authors: No reported Disclosures.

Risk score–guided multidisciplinary team-based Care for Heart Failure Inpatients is associated with lower 30-day readmission and lower 30-day mortality

Using augmented intelligence clinical decision tools and a risk score-guided multidisciplinary team-based care process (MTCP), this study evaluated the MTCP for heart failure (HF) patients' 30-day readmission and 30-day mortality across 20 Intermountain Healthcare hospitals. HF inpatient care and 30-day post-discharge management require quality improvement to impact patient health, optimize utilization, and avoid readmissions. HF inpatients (N = 6182) were studied from January 2013 to November 2016. In February 2014, patients began receiving care via the MTCP based on a phased implementation in which the 8 largest Intermountain hospitals (accounting for 89.8% of HF inpatients) were crossed over sequentially in a stepped manner from control to MTCP over 2.5 years. After implementation, patient risk scores were calculated within 24 hours of admission and delivered electronically to clinicians. High-risk patients received MTCP care (n = 1221), while lower-risk patients received standard HF care (n = 1220). Controls had their readmission and mortality scores calculated retrospectively (high risk: n = 1791; lower risk: n = 1950). High-risk MTCP recipients had 21% lower 30-day readmission compared to high-risk controls (adjusted P = .013, HR = 0.79, CI = 0.66, 0.95) and 52% lower 30-day mortality (adjusted P < .001, HR = 0.48, CI = 0.33, 0.69). Lower-risk patients did not experience increased readmission (adjusted HR = 0.88, P = .19) or mortality (adjusted HR = 0.88, P = .61). Some utilization was higher, such as prescription of home health, for MTCP recipients, with no changes in length of stay or overall costs. A risk score-guided MTCP was associated with lower 30-day readmission and 30-day mortality in high-risk HF inpatients. Further evaluation of this clinical management approach is required.

Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians.

Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27-44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examinedtheirpractice pattern variation by observing their diagnostic approaches andtheir adherence to the ACEP Clinical Policy. We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs. Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n = 38, 23.2%), (2) (n = 70, 42.7%), (3) (n = 56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects > 90% of SAH in those with a confirmed SAH [n = 150 (89.3%, 95% CI 83.6-93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n = 110 (65.5%, 95% CI 57.8-72.6)], some indicated a LP along with a CT [n = 57, 33.9% 95% CI 26.8-41.6)], and a few indicated both a CTA and a LP [n = 16, 9.5%, 95% CI 5.5-15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n = 25, 65.8%), (2) (n = 54, 77.1%), and (3) (n = 28, 50.0%) (p = 0.006). Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.

Surgeon-Level Variation in Utilization of Local Staging and Neoadjuvant Therapy for Stage II-III Rectal Adenocarcinoma

IntroductionNeoadjuvant therapy (NT) is the standard of care for clinical stage II-III rectal adenocarcinoma, but utilization remains suboptimal. We aimed to determine the underlying reasons for omission of local staging and NT. MethodsWe conducted a retrospective study of patients with clinical stage II-III or undocumented clinical stage/pathologic stage II-III rectal adenocarcinoma who were treated in 2010–2016 in one of nine Intermountain Healthcare hospitals. The outcomes of omission of local staging and NT were examined with multivariable models. Risk- and reliability-adjusted rates of local staging and NT were calculated for surgeons who treated ≥ 3 patients. Pathologic and long-term outcomes were examined after excluding patients who were not resected or who underwent local excision (N = 11). ResultsLocal staging was omitted in 43/240 (17.9%) patients and NT was omitted in 41/240 (17.1%). The strongest risk factors for local staging and NT omission were upper rectal tumors and surgeons who treated ≤ 3 cases/year. Thirty-six of 41 (87.8%) cases of omitted NT had local staging omitted. Adjusted surgeon-specific local staging rates varied 1.6-fold (56.3–92.4%) and NT rates varied 2.8-fold (34.1–97.1%). Surgeon local staging and NT rates were strongly correlated (r = 0.92). NT was associated with lower rates of positive circumferential radial margins (7.9 vs. 20.0%; P = 0.02), node positivity (33.3 vs. 55.0%; P = 0.01), and local recurrences (7.6 vs. 14.9% at 5 years; P = 0.0176). ConclusionsNT omission should be understood as a consequence of surgeon failure to perform local staging in most cases. Quality improvement efforts should focus on improving utilization of local staging.

Shared Leadership for Nursing

What is ‘shared leadership’, how does it work and how did five Intermountain Healthcare hospitals use it to help their employees become more engaged and their managers more efficient? Shared leadership — an organisational model that is designed to engage front-line staff in traditional management functions, improve communication and help individuals advance their careers — was implemented in 75 nursing units in 5 of Intermountain Healthcare’s hospitals in January 2014. The model involves three councils in each department: one focused on nursing practice issues, another on leadership issues and a third on patient and employee engagement. The goal of shared leadership is to increase involvement among front-line team members by giving them ownership for responsibilities that traditionally belong to nurse managers, and to give managers more time to lead by spending less time managing. The model also addressed two consistent challenges: The region’s nurse managers faced the constant need to do more with less. Employee surveys in the region showed that more employees wanted more control over their. Falling scores on one survey question — At work, do my opinions seem to count? — were a specific concern. A year after shared leadership was implemented, the model has produced four major benefits: 1. It engages the front-line staff 2. It creates value for the organisation 3. It improves communication 4. It develops individuals

Short-Term Exposure to Fine Particulate Matter Air Pollution Is Preferentially Associated With the Risk of ST-Segment Elevation Acute Coronary Events.

BackgroundAir pollution is associated with greater cardiovascular event risk, but the types of events and specific persons at risk remain unknown. This analysis evaluates effects of short‐term exposure to fine particulate matter air pollution with risk of acute coronary syndrome events, including ST‐segment elevation myocardial infarction, non–ST‐segment elevation myocardial infarction, unstable angina, and non–ST‐segment elevation acute coronary syndrome.Methods and ResultsAcute coronary syndrome events treated at Intermountain Healthcare hospitals in urban areas of Utah's Wasatch Front were collected between September 1993 and May 2014 (N=16 314). A time‐stratified case‐crossover design was performed matching fine particulate matter air pollution exposure at the time of each event with referent periods when the event did not occur. Patients served as their own controls, and odds ratios were estimated using nonthreshold and threshold conditional logistic regression models. In patients with angiographic coronary artery disease, odds ratios for a 10‐μg/m3 increase in concurrent‐day fine particulate matter air pollution >25 μg/m³ were 1.06 (95% CI 1.02–1.11) for all acute coronary syndrome, 1.15 (95% CI 1.03–1.29) for ST‐segment elevation myocardial infarction, 1.02 (95% CI 0.97–1.08) for non–ST‐segment elevation myocardial infarction, 1.09 (95% CI 1.02–1.17) for unstable angina, and 1.05 (95% CI 1.00–1.10) for non–ST‐segment elevation acute coronary syndrome events. Excess risk from fine particulate matter air pollution exposure was not observed in patients without angiographic coronary artery disease.ConclusionsElevated fine particulate matter air pollution exposures contribute to triggering acute coronary events, especially ST‐segment elevation myocardial infarction, in those with existing seriously diseased coronary arteries but not in those with nondiseased coronary arteries.

Abstract 15149: Short-term Exposure to Fine Particulate Matter Air Pollution Preferentially Increases the Risk of ST-Elevation Acute Coronary Events

Introduction: Air pollution is associated with greater cardiovascular event risk, but which types of events and the specific at-risk individuals remain unknown. Hypothesis: Short-term exposure to fine particulate matter (PM 2.5 ) is associated with greater risk of acute coronary syndromes (ACS), including ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (USA). Methods: ACS events treated at Intermountain Healthcare hospitals in Utah’s urban Wasatch Front region between September 10, 1993 and May 15, 2014 were included if the patient resided in that area (N=16,314). A time-stratified case-crossover design was performed matching the PM 2.5 exposure at the time of event with periods when the event did not occur (referent), for STEMI, NSTEMI, and USA. Patients served as their own controls. Odds ratios (OR) were determined for exposure threshold versus linear, non-threshold models. Results: In STEMI, NSTEMI, and USA patients, age averaged 62, 64, and 63 years; males constituted 73%, 66%, and 68%; current or past smoking was prevalent in 33%, 25%, and 26%; and significant coronary artery disease (CAD) (defined as ≥1 coronary with ≥70% stenosis) was found among 95%, 75%, and 74%, respectively. Short-term PM 2.5 exposure was associated with ACS events (Table). Conclusions: Short-term exposure of PM 2.5 was strongly associated with greater risk of STEMI, especially in patients with angiographic CAD. No association with NSTEMI was found, and only a weak effect for USA. This study supports a PM 2.5 exposure threshold of 25 μg/m 3 , below which little exposure effect is seen, while the effect is linear above that level.

Pulmonary-Specific Intermountain Risk Score Predicts All-Cause Mortality via Spirometry, the Red Cell Distribution Width, and Other Laboratory Parameters.

Pulmonary function testing parameters predict cardiovascular and mortality outcomes. Previously, risk scores were created using the basic metabolic profile and complete blood count, including the Intermountain Risk Score (IMRS). This study sought to develop similar pulmonary-specific risk scores for mortality prediction. Subjects evaluated by spirometry at 5 Intermountain Healthcare hospitals (females: n = 2,943; males: n = 2,495) were randomly assigned to risk score derivation (70% of subjects) or an independent validation set (the remaining 30%). Sex-specific scores used spirometry, age, and metabolic and blood count laboratory data. Cox regression β-coefficients formed the basis of risk score weightings. Among females, pulmonary IMRS was strongly associated with 5-y mortality in the validation set (hazard ratio = 1.24 per +1 risk score, CI 1.16-1.33, P trend < .001), with C-statistics of C = 0.835 and C = 0.757 for derivation and validation, respectively. Among males, validation results were similarly significant (hazard ratio = 1.20 per +1 risk score value, CI 1.11-1.28, P trend < .001), with C = 0.755 and C = 0.699 in derivation and validation sets, respectively. Results were stronger for pulmonary basic metabolic profile risk score, with females having C = 0.815 (derivation) and C = 0.806 (validation), whereas males had C = 0.734 and C = 0.731. Pulmonary-specific IMRS and pulmonary-specific basic metabolic profile risk score provided excellent discrimination of mortality among pulmonary subjects. These risk stratification tools combine familiar, relatively inexpensive, commonly-measured, standardized laboratory parameters with spirometry data. They may be electronically calculated and delivered at the point of care, providing meaningful risk information to assist clinicians in patient evaluations.

Impact of an Electronic Clinical Decision Support Tool for Emergency Department Patients With Pneumonia

Despite evidence that guideline adherence improves clinical outcomes, management of pneumonia patients varies in emergency departments (EDs). We study the effect of a real-time, ED, electronic clinical decision support tool that provides clinicians with guideline-recommended decision support for diagnosis, severity assessment, disposition, and antibiotic selection. This was a prospective, controlled, quasi-experimental trial in 7 Intermountain Healthcare hospital EDs in Utah's urban corridor. We studied adults with International Classification of Diseases, Ninth Revision codes and radiographic evidence for pneumonia during 2 periods: baseline (December 2009 through November 2010) and post-tool deployment (December 2011 through November 2012). The tool was deployed at 4 intervention EDs in May 2011, leaving 3 as usual care controls. We compared 30-day, all-cause mortality adjusted for illness severity, using a mixed-effect, logistic regression model. The study population comprised 4,758 ED pneumonia patients; 14% had health care-associated pneumonia. Median age was 58 years, 53% were female patients, and 59% were admitted to the hospital. Physicians applied the tool for 62.6% of intervention ED study patients. There was no difference overall in severity-adjusted mortality between intervention and usual care EDs post-tool deployment (odds ratio [OR]=0.69; 95% confidence interval [CI] 0.41 to 1.16). Post hoc analysis showed that patients with community-acquired pneumonia experienced significantly lower mortality (OR=0.53; 95% CI 0.28 to 0.99), whereas mortality was unchanged among patients with health care-associated pneumonia (OR=1.12; 95% CI 0.45 to 2.8). Patient disposition from the ED postdeployment adhered more to tool recommendations. This study demonstrates the feasibility and potential benefit of real-time electronic clinical decision support for ED pneumonia patients.

Abstract 18978: Predictive Modeling of 30-day Readmission of Heart Failure Patients Using Admit Labs, Early Clinical Tests, and History and Physical Exam for In-Hospital Modification of Readmission Risk

Background: All 30-day readmission risk models created to date use hospital discharge data gathered at the end of a hospital’s direct patient impact. Since 30-day readmission penalties are charged to hospitals, predictive models should use data from the time of index admission. This study created risk scores for 30-day readmission from factors available at admission among heart failure (HF) patients. Methods: HF patients aged 65 years or older who were admitted as inpatients to Intermountain Healthcare hospitals from 2005-2012 and not discharged to hospice were studied. Data included 205 predictor variables gathered within 24 hours of index admission and the 30-day readmission outcome. Patients were randomly divided into derivation (70%) and validation (30%) groups. Logistic regression was used to build sex-specific predictive models for 30-day readmission, including all variables (full model), only clinical and H&amp;P factors (clinical model), and only laboratory tests (lab model). Results: C-statistics for Intermountain HF risk scores (iHF) were greater than previous 30-day readmission models for HF patients (Table). Odds ratios (OR) for 30-day readmission for iHF (full model) in validation patients were, for females, OR=1.77 (95% CI=1.17, 2.66; p=0.007) and OR=1.62 (CI=1.07, 2.45) for tertiles 3 vs. 1 and 2 vs. 1, respectively. Among males in the validation group, the iHF full model had OR=2.28 (CI=1.53, 3.38; p&lt;0.001) for tertile 3 vs. 1 for 30-day readmission and, for tertile 2 vs. 1, OR=1.59 (CI=1.05, 2.41). Clinical and lab models were also very predictive despite using a reduced set of variables. Conclusions: The iHF readmission risk scores strongly stratified 30-day readmission risk using HF patient data available within 24 hours of index hospital admission. Discrimination was better than other HF 30-day readmission models, including those created for CMS. Use of iHF at the time of admission empowers hospital-based modification of 30-day readmission risk.

Late effects among testicular cancer survivors (1994-2011).

1582 Background: More than 95% of testicular cancer (TC) patients survive at 10 years; however, they develop many complications following diagnosis. Our study is toassess the risk of developing morbidities among TC survivors. Methods: We used the Utah Population Database to identify TC patients (age&gt;13) who 1) were diagnosed between 1994 and 2008, 2) had medical records at the University of Utah and Intermountain Health Care hospitals and 3) survived at least 3 years. Cases were matched to five TC-free patients (controls) from the same hospitals on birth year, birth region and date of residence in Utah. Individuals (cases and controls) with morbidities of interest before the date of TC diagnosis were excluded. Adjusted Cox regression analysis was used to identify the risk of developing ischemic heart disease, renal failure, infertility, hearing loss, peripheral neuropathy, osteoporosis and restrictive lung disease among TC patients relative to controls. The models were adjusted for age, race and other confounders. We also compared the risk of these morbidities among patients with regional/advanced tumor relative to patients with in situ/localized tumor. The latter was adjusted for age and tumor histology. Results: We identified 955 TC patients and 4775 controls. TC stage was: 73.7 % in situ/localized and 26.3% regional/advanced. The hazard rate (HR) of developing any of the target morbidities was 2.57, 95% confidence interval (CI), 2.2-2.9 for patients with localized cancer, 3.85 (95% CI: 2.9-5.1) for patients with regional cancer and 3.3 (95% CI: 2.3-4.8) for patients with advanced cancer relative to controls. Risk of developing renal failure, infertility, peripheral neuropathy, hearing loss and restrictive lung disease was significantly higher among TC survivors (P&lt;0.05). We also identified a significant association (HR 5.2; 95% CI 1.8-15.5) of cancer stage and the risk of developing hearing loss and non-significant positive association of TC stage with the other morbidities. Conclusions: TC survivors were more than twice as likely to develop morbidities following diagnosis when compared to controls. The risk increases when the comparison is stratified by stage, which might be related to the differences in the treatment used for different stages of TC.