Lower Rates Of Emergency Department Visits Research Articles

Clinical outcomes in patients with mild to moderate coronavirus disease 2019 treated with monoclonal antibody therapy versus an untreated control cohort.

Monoclonal antibody therapy (MAT) received Food and Drug Administration (FDA) Emergency Use Authorization (EUA) for mild to moderate COVID-19 treatment in adults at a high-risk for progression to severe disease in November 2020. This study assessed the impact of MAT on clinical outcomes. We conducted a single-center, retrospective study comparing 30-day COVID-19-related emergency department (ED) visits, admissions, and mortality in patients receiving MAT (bamlanivimab, bamlanivimab-etesevimab, or casirivimab-imdevimab) between 16 November 2020 and 19 June 2021, compared to a control group of high-risk adults diagnosed with mild to moderate COVID-19 prior to MAT availability between 16 May 2020 and 15 November 2020. Statistical analysis used logistic regression analysis with backward selection to determine the odds ratios and 95% confidence interval evaluating the relationship between clinical characteristics and outcomes. 1187 patients who received MAT were compared to 1103 patients not treated with MAT. Multivariable regression model adjusted for possible confounders showed patients who received MAT had lower rates of ED visits (3.2% vs 7.4%, OR = 0.46, 95% CI = 0.31-0.70, p < .001) and hospital admissions (4.3% vs 7.8%, OR = 0.42, 95% CI = 0.29-0.62, p < .001) compared to the control group. After adjusting for confounders, MAT was associated with decreased mortality (OR = 0.36, p = .035). In the MAT group, those treated within 2 days of COVID-19 diagnosis had lower mortality than those treated more than 2 days post-diagnosis (unadjusted OR = 0.152, 95% CI = 0.031-0.734, p = .019). Individuals treated with MAT had lower rates of 30-day COVID-19-related ED visits and hospital admissions compared to those not receiving MAT. Early MAT resulted in lower 30-day mortality compared to receipt >2 days post COVID-19 diagnosis.

Structured Evaluation and Management of Patients with COPD in an Accredited Program.

Chronic obstructive pulmonary disease (COPD) is an ambulatory care-sensitive condition. We compared the impact of care received by patients with COPD at Joint Commission-accredited, disease-specific clinics and primary care clinics at an academic health care systemfrom April 2014 to March 2018. Patients with COPD ≥ 40 years old with ≥ 2 outpatient visits 30 days apart were identified. Baseline demographics, disease-specific performance measures, and health care utilization were compared between groups. Propensity matching was conducted and time to the first emergency department (ED) visit and hospitalization was performed using Cox regression analysis. Of 4646 unique patients with COPD, 1114 were treated at disease-specific clinics and 3532 at primary care clinics. The entire group was predominantly female (58.8 %), non-Hispanic White (74.2 %) with a mean age of 65.4 ± 11.4 years consisting of current (47.6 %) or former smokers (38.4 %). In the disease-specific group, performance measures were performed more frequently, and lower rates of ED visits (hazard ratio [HR]=0.31, 95% confidence interval [CI] 0.18-0.54) and hospitalizations (HR 0.41, 95% CI 0.21-0.79) noted in comparison to the primary care group. In this observational study, the implementation of achronic disease management program through accredited disease-specific clinics for patients with COPD was associated with reduced all-cause ED visits and hospitalizations.

Impact of distress screening and referral on health care utilization and cost among breast cancer patients: a retrospective cohort study ∗

Abstract Background: Addressing cancer patient distress and unmet needs may reduce health care costs and enhance care utilization. This study examined the impact of a distress screening program CancerSupportSource™ (CSS) on health care utilization and costs for breast cancer patients. Methods: In a retrospective cohort study with 2 years’ follow-up, breast cancer patients receiving care at a community cancer center in Orlando, FL, between 2016 and 2019 were categorized according to exposure status: screened using CSS and acted by using supportive care services (SA); screened only (SO); and not screened (NS). Patients were matched on breast tumor location and age; screened patients were additionally matched on referral need. Outcomes abstracted from medical records included utilization and cost of emergency department (ED) services, hospital inpatient admissions, and outpatient services; and utilization of integrative medicine department, patient/family counseling, and allied health services. Results: SA patients (n = 36), compared to NS (n = 37), had significantly lower rates of ED visits in negative binomial regression analysis (incidence rate ratio [IRR] 0.43; 95% confidence interval [CI] 0.20–0.93; P = .031). There were significantly higher rates of integrative medicine department visits in SA (IRR 4.20; 95% CI 1.63–10.9; P = .003) and SO (IRR 3.71; 95% CI 1.49–9.24; P = .005) groups compared to NS, and higher rates of patient/family counseling visits in SA (IRR 6.21; 95% CI 1.52–25.3; P = .011). There were no significant differences in 2-year health care costs between groups, controlling for age and race/ethnicity. Conclusions: These findings highlight the potential value of distress screening and referral for health care utilization, shifting use of higher cost services to lower cost nonemergent and preventive care in cancer, and can inform future prospective research on cost outcomes.

Healthcare resource utilization following ECG sensor patch screening for atrial fibrillation.

BackgroundScreening for asymptomatic, undiagnosed atrial fibrillation (AF) has the potential to allow earlier treatment, possibly resulting in prevention of strokes, but also to increase medical resource utilization.ObjectiveTo compare healthcare utilization rates during the year following initiation of screening among participants screened for AF by electrocardiogram (ECG) sensor patch compared with a matched observational control group.MethodsA total of 1718 participants recruited from a health care plan based on age and comorbidities who were screened with an ECG patch (actively monitored group) as part of a prospective, pragmatic research trial were matched by age, sex, and CHA2DS2-VASc score with 3371 members from the same health plan (observational control group). Healthcare utilization, including visits, prescriptions, procedures, and diagnoses, during the 1 year following screening was compared between the groups using health plan claims data.ResultsOverall, the actively monitored group had significantly higher rates of cardiology visits (adjusted incidence rate ratio [aIRR] [95% confidence interval (CI)]: 1.43 [1.27, 1.60]), no difference in primary care provider visits (aIRR [95% CI]: 1.0 [0.95, 1.05]), but lower rates of emergency department (ED) visits and hospitalizations (aIRR [95% CI]: 0.80 [0.69, 0.92]) compared with controls. Among those with newly diagnosed AF, the reduction in ED visits and hospitalizations was even greater (aIRR [95% CI]: 0.27 [0.17, 0.43]).ConclusionAF screening in an asymptomatic, moderate-risk population with an ECG patch was associated with an increase in cardiology outpatient visits but also significantly lower rates of ED visits and hospitalizations over the 1 year following screening.

P802 Probability of vedolizumab response as defined by clinical decision support tool is associated with lower healthcare utilisation in patients with Crohn’s disease

Abstract Background A clinical decision support tool (CDST) has been developed and validated for predicting treatment effectiveness of vedolizumab (VDZ) in Crohn’s disease (CD). We evaluated this tool’s ability to predict healthcare resource utilisation using real-world data. Methods CD patients treated with VDZ were identified using real-world data from the Optum (n = 358) and Truven MarketScan (n = 1445) databases. The full CDST with 3 clinical variables (prior bowel surgery, prior fistulising disease, prior TNF-antagonist exposure) and 2 lab values (albumin and CRP) was applied to the Optum dataset with available lab data, and patients were stratified into low (n = 27), intermediate (n = 152), or high (n = 179) probability of response groups. A modified weighting of the 3 clinical variables was created for application in Truven MarketScan due to the lack of availability of lab data. To assess the coherence with the full 5-variable CDST, the modified 3-variable CDST was used to stratify Optum patients into low (n = 137) or high (n = 221) probability of response, and then subsequently validated in the Truven MarketScan dataset (low, n = 510; high n = 935; response probability groups). Rates of hospitalisation, surgery, emergency department (ED) visits and annualised per patient costs were compared across response probability groups. Results Using the full 5-variable CDST, we observed a linear trend of significantly lower rates of ED visits, hospitalisation, surgery, and healthcare-related costs with increasing probability of response (Table). These results were consistent when using the modified 3 variable CDST in the Optum patient dataset where we observed a 3-fold higher rate of per patient healthcare costs in the low probability of response group compared with the high probability of response group ($6535 vs. $1900, p = 0.016). In the Truven patient dataset, the modified 3 variable CDST was also associated with a significantly lower rate of hospitalisation, surgery, and healthcare costs in the high probability of response group (Table). The majority of cost differences between high and low response groups was driven by costs related to hospitalisation and surgery. Conclusion A simple CDST can identify CD patients treated with VDZ who present a higher risk for healthcare resource utilisation, especially for hospitalisation and surgery. This tool could be integrated into population health monitoring algorithms using real-world data and offer flexibility on requirements of lab data.

Improving Outcomes of Care for HRSA-Funded Health Center Patients Who Have Mental Health Conditions and Substance Use Disorders.

The rising prevalence of mental health conditions and substance use disorders (MH/SUD) underscores the important role of health centers (HCs) in caring for low-income and uninsured MH/SUD patients. This study used the 2014 Health Center Patient Survey and 2014 Uniform Data System to determine the independent association between delivery of MH/SUD integration and related interventions to patients that reported a MH/SUD condition (n=2714) with the number of HC visits, emergency department (ED) visits, and hospitalizations last year. Results showed that health education was associated with fewer predicted ED visits (1.8 vs. 2.3) and lower likelihood of hospitalizations (16% vs. 24%) among MH patients. Medical enabling services was associated with lower rates of ED visits (0.3 vs.1.9) and hospitalizations (< 1% vs. 13%) among SUD patients. The results indicate the utility of integration and related intervention services in primary care settings to improve service use and reduce ED and hospitalization among MH/SUD patients.

The utilization of video-conference shared medical appointments in rural diabetes care

AimTo explore whether Video-Shared Medical Appointments (video-SMA), where group education and medication titration were provided remotely through video-conferencing technology would improve diabetes outcomes in remote rural settings. MethodsWe conducted a pilot where a team of a clinical pharmacist and a nurse practitioner from Honolulu VA hospital remotely delivered video-SMA in diabetes to Guam. Patients with diabetes and HbA1c ≥7% were enrolled into the study during 2013–2014. Six groups of 4–6 subjects attended 4 weekly sessions, followed by 2 bi-monthly booster video-SMA sessions for 5 months. Patients with HbA1c ≥7% that had primary care visits during the study period but not referred/recruited for video-SMA were selected as usual-care comparators. We compared changes from baseline in HbA1c, blood-pressure, and lipid levels using mixed-effect modeling between video-SMA and usual care groups. We also analyzed emergency department (ED) visits and hospitalizations. Focus groups were conducted to understand patient’s perceptions. ResultsThirty-one patients received video-SMA and charts of 69 subjects were abstracted as usual-care. After 5 months, there was a significant decline in HbA1c in video-SMA vs. usual-care (9.1±1.9 to 8.3±1.8 vs. 8.6±1.4 to 8.7±1.6, P=0.03). No significant change in blood-pressure or lipid levels was found between the groups. Patients in the video-SMA group had significantly lower rates of ED visits (3.2% vs. 17.4%, P=0.01) than usual-care but similar hospitalization rates. Focus groups suggested patient satisfaction with video-SMA and increase in self-efficacy in diabetes self-care. ConclusionVideo-SMA is feasible, well-perceived and has the potential to improve diabetes outcomes in a rural setting.

Process and Outcome Measures among COPD Patients with a Hospitalization Cared for by an Advance Practice Provider or Primary Care Physician.

ObjectivesTo examine the process and outcomes of care of COPD patients by Advanced Practice Providers (APPs) and primary care physicians.MethodsWe conducted a cross sectional retrospective cohort study of Medicare beneficiaries with COPD who had at least one hospitalization in 2010. We examined the process measures of receipt of spirometry evaluation, influenza and pneumococcal vaccine, use of COPD medications, and referral to a pulmonary specialist visit. Outcome measures were emergency department (ER) visit, number of hospitalizations and 30-day readmission in 2010.ResultsA total of 7,257 Medicare beneficiaries with COPD were included. Of these, 1,999 and 5,258 received primary care from APPs and primary care physicians, respectively. Patients in the APP group were more likely to be white, younger, male, residing in non-metropolitan areas and have fewer comorbidities. In terms of process of care measures, APPs were more likely to prescribe short acting bronchodilators (adjusted odds ratio [aOR] = 1.18, 95%Confidence Interval [CI] 1.05–1.32), oxygen therapy (aOR = 1.25, 95% CI 1.12–1.40) and consult a pulmonary specialist (aOR = 1.39, 95% CI 1.23–1.56), but less likely to give influenza and pneumococcal vaccinations. Patients receiving care from APPs had lower rates of ER visits for COPD (aOR = 0.84, 95%CI 0.71–0.98) and had a higher follow-up rate with pulmonary specialist within 30 days of hospitalization for COPD (aOR = 1.25, 95%CI 1.07–1.48) than those cared for by physicians.ConclusionsCompared to patients cared for by physicians, patients cared for by APPs were more likely to receive short acting bronchodilator, oxygen therapy and been referred to pulmonologist, however they had lower rates of vaccination probably due to lower age group. Patients cared for by APPs were less like to visit an ER for COPD compared to patients care for by physicians, conversely there was no differences in hospitalization or readmission for COPD between MDs and APPs.

Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure

Heart failure (HF) frequently causes hospital admission and readmission. Patients receiving care from multiple providers and facilities (dual users) may risk higher health care utilization and worse health outcomes. To determine rates of emergency department (ED) visits, hospitalizations, and hospital readmissions relative to dual use among HF patients, we analyzed a retrospective cohort of 13,977 veterans with HF hospitalized at the Veterans Affairs (VA) or non-VA facilities from 2007 to 2011; we analyzed rates of acute health care utilization using zero-inflated negative binomial regression. Compared to VA-only users and dual users, individuals receiving all of their ED and hospital care outside the VA tended to be older, more likely to be non-Hispanic white and married, and less likely to have high levels of service connected disability. Compared to VA-only users, dual users had significantly higher rates of ED visits for HF as a primary diagnosis (adjusted rate ratio 1.15, 95% CI 1.04-1.27), hospitalization for HF (adjusted rate ratio 1.4, 95% CI 1.26-1.56), hospital readmission after HF hospitalization (all cause) (1.46, 95% CI 1.30-1.65), and HF-specific hospital readmission after HF hospitalization (1.46, 95% CI 1.31-1.63). With the exception of hospitalization for any primary diagnosis, non-VA-only users had significantly lower rates of ED visits, hospitalization, and readmission compared to VA-only users. Dual use is associated with higher rates of health care utilization among patients with HF. Interventions should be devised to encourage continuity of care where possible and to improve the effectiveness and safety of dual use in instances where it is necessary or desired.

Targeted Therapy at the End-of-Life and the Impact on Healthcare Utilization (S807)

•Describe the use of targeted therapy in cancer treatment at the end-of-life.•Identify the patterns of healthcare utilization observed at the end-of-life for those treated with chemotherapy and targeted therapies. The use of targeted therapy has steadily increased over the past decade, though the impact of targeted agents on patterns of care at the end-of-life remains unknown. To explore the influence of targeted therapy on end-of-life care in a large population-based database. We identified 14,398 patients from the SEER-Medicare linked database with metastatic breast, lung, or colorectal cancer diagnosed between 2000 and 2009 who received conventional cytotoxic chemotherapy or targeted therapy in the last 3 months of life. Multivariate logistic and linear regression models were used to determine the impact of targeted therapy on the following endpoints in the last 3 months: emergency department (ED) visits, hospitalizations, and hospice utilization. Analyses were adjusted for differences in patient age, gender, race, comorbidity, socioeconomic status, and geography. Among the whole study cohort 83% of patients received chemotherapy alone, 12% received chemotherapy with targeted therapy, and 5% received targeted therapy alone. The delivery of any targeted therapy in the last 3 months increased across the study period, from 1.5% in 2000 to 28% in 2009. Compared to patients treated with chemotherapy alone, those treated with targeted therapy alone had lower rates of ED visits (adjusted odds ratio [aOR]=0.81, p=0.01), lower rates of hospitalization (adjusted odds ratio [aOR]=0.69, p<0.0001), no difference in overall hospice utilization rates, though had longer stays on hospice (5.1 days longer, p<0.0001). Compared to patients treated with chemotherapy alone, those treated with both chemotherapy and targeted therapy had no difference in ED visits or hospitalizations, though had decreased rates of hospice utilization (aOR = 0.79, p<0.0001), and shorter stays on hospice (2.7 days shorter, p<0.0001). This study found that targeted therapy was associated with varying patterns of healthcare utilization at the end-of-life.

Targeted therapy at the end of life and the impact on health care utilization.

116 Background: The use of targeted therapy has steadily increased over the past decade, though the impact of targeted agents on patterns of care at the end-of-life life remains unknown. The purpose of this study was to explore the influence of targeted therapy on end-of-life care in a large population-based database. Methods: We identified 14,398 patients from the SEER-Medicare linked database with metastatic breast, lung, or colorectal cancer diagnosed between 2000 and 2009 who received conventional cytotoxic chemotherapy or targeted therapy in the last 3 months of life. Multivariate logistic and linear regression models were used to determine the impact of targeted therapy on the following endpoints in the last 3 months of life: emergency department (ED) visits, hospitalizations, and hospice utilization. Analyses were adjusted for differences in patient age, gender, race, comorbidity, socioeconomic status, and geography. Results: Among the whole study cohort 83% of patients received chemotherapy alone, 12% received chemotherapy with targeted therapy, and 5% received targeted therapy alone. The delivery of any targeted therapy in the last 3 months increased across the study period, from 1.5% in 2000 to 28% in 2009. Compared to patients treated with chemotherapy alone, those treated with targeted therapy alone had lower rates of ED visits (adjusted odds ratio [aOR]=0.81, p=0.01), lower rates of hospitalization (adjusted odds ratio [aOR]=0.69, p&lt;0.0001), no difference in overall hospice utilization rates, though had longer stays on hospice (5.1 days longer, p&lt;0.0001). Compared to patients treated with chemotherapy alone, those treated with both chemotherapy and targeted therapy had no difference in ED visits or hospitalization admission rates, though had decreased rates of hospice utilization (aOR = 0.79, p&lt;0.0001), and shorter stays on hospice (2.7 days longer, p&lt;0.0001). Conclusions: This study found that targeted therapy was associated with varying patterns of healthcare utilization at the end-of-life, though these differences could be influenced by unknown confounding variables. Future research should focus on defining the specific impact of targeted therapy on quality of life at the end-of-life.

Anti-Inflammatory Medication Adherence, Healthcare Utilization and Expenditures among Medicaid and Childrenʼs Health Insurance Program Enrollees with Asthma

Underuse of controller therapy among Medicaid-enrolled children is common and leads to more emergency department (ED) visits and hospitalizations. However, there is little evidence about the relationship between medication adherence, outcomes and costs once controller therapy is initiated. This study examined the relationship between adherence to two commonly prescribed anti-inflammatory medications, inhaled corticosteroids (ICS) and leukotriene inhibitors (LI), and healthcare utilization and expenditures among children enrolled in Medicaid and the Children's Health Insurance Program in Florida and Texas in the US. The sample for this retrospective observational study consisted of 18,456 children aged 2-18 years diagnosed with asthma, who had been continuously enrolled for 24 months during 2004-7 and were on monotherapy with ICS or LI. State administrative enrolment files were linked to medical claims data. Children were grouped into three adherence categories based on the percentage of days per year they had prescriptions filled (medication possession ratio). Bivariate and multivariable regression analyses that adjusted for the children's demographic and health characteristics were used to examine the relationship between adherence and ED visits, hospitalizations, and expenditures. Average adherence was 20% for ICS-treated children and 28% for LI-treated children. Children in the highest adherence category had lower odds of an ED visit than those in the lowest adherence category (p<0.001). We did not detect a statistically significant relationship between adherence and hospitalizations; however, only 3.7% of children had an asthma-related hospitalization. Overall asthma care expenditures increased with greater medication adherence. Although greater adherence was associated with lower rates of ED visits, higher medication expenditures outweighed the savings. The overall low adherence rates suggest that quality improvement initiatives should continue to target adherence regardless of the class of medication used. However, low baseline hospitalization rates may leave little opportunity to significantly decrease costs through better disease management, without also decreasing medication costs.