Mean Number Of Hospitalizations Research Articles

Economic burden of hepatitis B infection among patients with diabetes

ABSTRACTDespite ACIP recommendation and cost-effectiveness established in those 19–59 y old diabetes patients the uptake of Hepatitis B vaccine in diabetes patients is low. There is need to highlight the impact of Hepatitis B virus (HBV) infection in diabetes patients in terms of healthcare utilization and costs to recognize the burden of HBV in this population.This retrospective claims analysis included patients with diabetes and HBV (cases; n=1,236) and those with diabetes without HBV (controls; n=4,944), identified by ICD-9-CM diagnosis codes. Cases were matched with 4 controls using propensity score matching. Healthcare utilization and cost were compared; incremental effect of HBV infection was assessed using multivariate analysis.In the adjusted analyses, the mean number of hospitalizations (0.6 vs 0.4), outpatient service visits (34.2 vs. 20.4), and office visits (10.9 vs. 9.8) were 41%, 68%, and 11% higher, respectively, in cases vs. controls (all p<0.05). Gastroenterologist visits (0.8 vs. 0.2) and infectious disease visits (0.1 vs. 0.0) were 80% and 18% higher in subset of case and controls with these events. Cases ($39,435) incurred $16,397 incremental total costs compared with controls ($23,038). Medical ($30,968 vs. $17,765) and pharmacy costs ($8,029 vs. $5,114) were both significantly higher for cases (p < 0.0001).Healthcare utilization and costs were higher among patients with diabetes and HBV than in those with diabetes alone. These results provide evidence supporting the need for HBV vaccination among unvaccinated diabetes patients.

Direct Costs of Acute Recurrent and Chronic Pancreatitis in Children in the INSPPIRE Registry.

To estimate selected direct medical care costs of children with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). We performed a cross-sectional study of data from International Study Group of Pediatric Pancreatitis: In Search for a Cure (INSPPIRE), a multinational registry of children with ARP or CP. We determined health care utilization and estimated costs of hospitalizations, surgical and endoscopic procedures, and medications in our study population. Health care utilization data were obtained from all subjects enrolled in the study, and costs were calculated using national United States costs. We included 224 subjects (median age 12.7 years), 42% of whom had CP. Mean number of hospitalizations, including for surgery and endoscopic retrograde cholangiopancreatography, was 2.3 per person per year, costing an estimated average $38,755 per person per year. Including outpatient medications, estimated total mean cost was $40,589 per person per year. Subjects using surgical procedures or endoscopic retrograde cholangiopancreatography incurred mean annual costs of $42,951 per person and $12,035 per person, respectively. Estimated annual costs of pancreatic enzyme replacement therapy, diabetic medications, and pain medications were $4114, $1761, and $614 per person, respectively. In an exploratory analysis, patients with the following characteristics appear to accrue higher costs than those without them: more frequent ARP attacks per year, reported constant or episodic pain, family history of pancreatic cancer, and use of pain medication. ARP and CP are uncommon childhood conditions. The severe burden of disease associated with these conditions and their chronicity results in high health care utilization and costs. Interventions that reduce the need for hospitalization could lower costs for these children and their families.

Angiopoietin-2 concentration in serum is associated with severe asthma phenotype.

BackgroundSeveral proangiogenic molecules have been implicated in the pathogenies of asthmatic inflammation and remodeling. The aim of the study was to compare the concentration of proangiogenic factors in the sera of asthmatic patients and in healthy subjects (HS), and to refer the concentrations to both clinical and inflammatory markers of the disease severity.MethodsSerum was collected from 45 patients with severe/refractory asthma (SRA) and 51 patients with non-severe asthma (nSA). The control group included 30 HS. Serum concentrations of Angiopoietin-1, Angiopoietin-2, vascular endothelial growth factor (VEGF) and osteopontin were assessed by the enzyme-linked immunosorbent assay.ResultsThe levels of Angiopoietin-1 (68.8 ± 2.7 vs 56.4 ± 9.3 ng/ml; p < 0.05), Angiopoietin-2 (4.9 ± 0.35 vs 1.38 ± 0.14 ng/ml; p < 0.0001) and VEGF were significantly higher in asthmatic patients (n = 94) as compared to HS (255 ± 45.4 vs 424.5 ± 27.8 pg/ml; p < 0.01). The mean serum level of Angiopoietin-2 was found to be significantly higher in patients with SRA as compared to nSA patients (6.04 ± 0.46 vs 3.84 ± 0.43; p < 0.001). Angiopoietin-2 serum level correlated with respiratory function and with parameters of asthma severity: the mean number of asthma exacerbations in the preceding 12 months (R = 0.21; p < 0.05), mean number of emergency visits due to severe asthma exacerbation (R = 0.24; p < 0.04) and mean number of hospitalizations (R = 0.21; p < 0.05) or dose of inhaled glucocorticosteroids taken by the patients (R = 0.36; p < 0.001).ConclusionAngiopoietin-2 seems to be a crucial proangiogenic cytokine overproduced in patients with SRA characterized by repeated exacerbations and Angiopoietin-2 serum levels can serve as a biomarker of severe asthma.

Clinical predictors of clozapine response

IntroductionSchizophrenia is a chronic, severe, and disabling mental disorder. An evaluation of clinical predictors to clozapine was described.ObjectIdentify clinical predicting factors to clozapine.MethodsThis is a cross-sectional study including patients diagnosed with schizophrenia or schizoaffective disorder according to the DSM 5 criteria and treated with clozapine.ResultsOf the 33 patients, 78.8% were males and 69.7% of them were single. The mean age was 36 years old. The mean age at the onset of the disorder was 24 years old. The mean number of hospitalizations was 6. The beginning of the mental disorder was acute in 21.2% of the cases. The mean duration of the disease course before starting clozapine treatment was 11 years. The mean duration of treatment was 19 months. The diagnosis according to DSM 5 criteria was schizophrenia in 87.9 and schizoaffective disorder in 12.1% of cases. The outcome was assessed by PANSS and BPRS scales with a symptomatic remission in 63.63% of cases. The analytical study revealed a significant correlation between favorable evolution and the latest onset of the disorder (P = 0.04), the number of previous hospitalizations (P = 0.009), disorder's duration (P = 0.032), male sex (P = 0.0004) and secondary resistance (P &lt; 10−3).ConclusionThe evaluation of clinical factors is important in our practice in order to improve the response to clozapine. Otherwise, adherence to treatment and quality of insight are determining factors of the treatment response.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Increased Prevalence of Autoimmunity and Connective Tissue Diseases in Sickle Cell Disease

Connective tissue disease (CTD) and sickle cell disease (SCD) are diverse group of disorders; however, both of these diseases are characterized by underlying chronic inflammation. CTD is perceived to have a higher incidence and to affect the disease severity in SCD. Objectives: We seek to describe prevalence of autoimmunity and CTD and itsimpact on SCD disease severity as this is not well described in the literature. Methods: We retrospectively reviewed the medical records of 722 patients with SCD, seen over an 11 year period followed at a tertiary care hospital in London, UK. During the last 2 years of the study, number of hospitalizations and length of hospital stay were compared in patients with SCD with and without CTD. Results: In the study cohort, hemoglobin SS was the most common genotype (n = 451; 62%) and 411 (57%) were female. Twenty-three patients (3.1% had documented evidence of CTD, with rheumatoid arthritis (n = 14; 2%) and systemic lupus erythematosus (n = 2; 0.3%) being the most common. Antinuclear antibody was present in 108 (15%) of the patients and anti-smooth muscle antibody was present in 60 (8%). The mean number of hospitalizations (1.9 ± 2.7 vs. 1.5 ± 2.7) and mean length of hospital stay (6 days ± 4.1 vs. 7 days ± 11.4) were not different between those with or without autoimmunity and/or CTD. Avascular necrosis was the most common non-CTD musculoskeletal complication, affecting 72 (10%) patients. Conclusion: Our study suggests that positive autoimmune serology and CTD were more common in SCD compared to non-SCD population of similar ethnic background; however, presence of CTD does not appear to affect the SCD severity. The high frequency of CTD and overlapping of clinical symptoms suggest a need for diagnostic vigilance in diagnosing CTD in patients with SCD.

Healthcare Utilization Disparity between Caucasian and African-American Patients with Diabetes from 2006-2008 and 2009-2011

Objective: Type II Diabetes Mellitus has attached concern worldwide because of its impact on those with the disease, the growing costs to health systems, and chronic complications and comorbidities of the disease. The purpose of this study was to identify disparity of utilization of healthcare services among African Americans and Caucasians in the United States from 2006-2008 and 2009 and 2011. Design: Retrospective demographic data was acquired from the Medicare database via the Center for Medicare and Medicaid Services (CMS) from 2006- 2011 using files derived from inpatient charts and insurance carrier data was analyzed by independent t-test. Subjects: The sample from 2006-2008 included men and women; 181,857 Caucasians and 29,527 African Americans. The sample from 2009-2011, included 140,172 Caucasians and 23,898 African Americans. Main Outcome Measures: Number of hospital stays, length of hospital stay, number of physician office visits, number of physical therapy visits, and incidence of lower limb amputations. Results: An analysis of temporal changes in these populations revealed that the mean number of hospital stays decreased from 3.05 to 2.05 for African Americans and from 2.63 to 1.86 for Caucasians, P<0.001. The length of hospital stays decreased for African Americans from 21.11 to 15.61 days and in Caucasians from 13.87 to 11.01 days. The number of lower limb amputations decreased for both groups, but African Americans saw a more significant drop from 1.6% to 0.7%. The mean number of doctor visits for African Americans decreased from 21.28 to 8.91 and Caucasians from 24.72 to 9.59. The mean number of physical therapy visits in African Americans decreased 19.56 to 17.19 and Caucasians 25.15 to 20.91. Conclusion: Health care disparities in the utilization of health care for DMII exist between African Americans and Caucasians. Caucasians are more likely to visit physicians and physical therapists while African Americans are more likely to go to hospitals, stay longer in hospitals, and have lower limb amputations. The causes of these disparities between African Americans and Caucasians require further investigation for complete understanding.

Impact of an initial supportive oncology clinic visit on hospitalizations and emergency department visits.

150 Background: Hospitalizations and emergency department (ED) visits can be frequent, costly and discordant with stated goals-of-care for cancer patients. Little is known about the impact of outpatient palliative care and supportive oncology on hospitalizations and ED visits. Our aim was to investigate the impact of an initial visit at an outpatient supportive oncology clinic (SOC) on patient hospitalizations and ED visits. Methods: New patients were referred to a SOC from our health system’s oncologists from November 1, 2014 through January 31, 2015. Visits include a structured symptom assessment and personalized treatment plan from the clinic’s physician and/or nurse practitioner. Data were collected 90 days retrospectively and 90 days prospectively from 134 consecutive initial SOC visits. Descriptive statistics were calculated. We used the Wilcoxon signed rank test to compare the mean number of hospitalizations and ED visits in the 90 days prior and 90 days post a patient’s first SOC visit. Results: Mean patient age at first SOC visit was 55.6 (SD = 16.4). 51.2% of patients were female. The most common cancers were breast, lung, head and neck. Mean number of hospitalizations per patient was significantly (p &lt; 0.05) decreased: 1.3 (SD = 1.6) in the 90 days prior to initial SOC visit vs. 0.7 (SD = 0.7) in the 90 days post initial SOC visit. There was a non-significant reduction in mean ED visits per patient: 0.9 (SD = 0.9) in the 90 days prior to initial SOC visit vs. 0.7 (SD = 0.7) in the 90 days post initial SOC visit. Conclusions: Hospitalizations were significantly decreased and ED visits were reduced after the first visit to a small-scale SOC. This provides evidence that outpatient supportive care including aggressive symptom management may reduce patient crises, preventing ED visits and hospitalizations, and will likely lead to cost savings and improve quality of life for patients during and after cancer therapy. The decrease in hospitalizations and ED visits may be underestimated if disease was progressing and overestimated if disease was shrinking, but this data was not available for this study.

Clinical and Psychological Correlations between Job Loss and Depressive Experience

Abstract Introduction: Stressful life events have a negative effect on mental health. Job loss is an event with a psychotraumatic character. Identification of the main sources of stress faced by the individual is essential in the management of depression. Objective: The aim of this study was to identify the main risk factors that play a role in the onset and maintenance of depression. Material and methods: we made a prosepctive study including 68 outpatients aged over 18, recently diagnosed with Major Depressive Disorder (MDD), without psychotic features, with initiated antidepressant treatment, being in evidence of First Clinic of Psychiatry Tirgu-Mures, between 01.01.2013-31.12.2013. To assess the severity of depression and to measure the antidepressant treatment efficacy we used Hamilton Depression Scale (HAM-D17) at study onset, respectively at endpoint. The parameters followed were: HAM-D17 score, response to treatment, the mean number of hospitalizations in a year. Results: The group included 82.35% women and 17.65% men, mostly from urban areas, aged between 35 and 68, with a HAM-D17 score between 24 and 27. The major stressful life events inventory shows that 20.58 % of the patients were unemployed. The observed effects were more extensive in men. Conclusions: How stressful life events exert their influence on mood is complex. The onset of depression often seems to coincide with a stressful event, although sometimes the event is only the revelator of an episode ready to trigger. The findings indicate the need of prevention politics for relapse of the disease, which is a disadvantage regarding the re-employment.

Abstract PD4-4: Prevalence, health care utilization and costs of concomitant depression among breast cancer survivors

Abstract Purpose: Concomitant conditions in a cohort of non-elderly breast cancer survivors (BCS) were examined with a focus on the prevalence, healthcare utilization, and costs of diagnosed depression. Little research has been conducted on how concomitant depression among cancer survivors impacts utilization and costs of care. Methods. Using administrative claims data from the Military Health System Data Repository (MHSDR), a cohort of 2,851 BCS was identified with at least 2 years survival from the time of diagnosis. Concomitant conditions were based on ICD-9 codes; codes 296.2, 296.3, 298.0, and 311 were used to identify depression. Fiscal year 2009 was used as the index year to calculate healthcare utilization and costs. Bivariate analyses and logistic regression analysis were used to examine group differences and predictors of having received a diagnosis of depression. Findings. The most common concomitant chronic conditions in the BCS cohort were hypertension (50.0%), mood disorders or adjustment disorders (37.5%), heart disease (23.0%), diabetes (19.9%), history of tobacco use (19.7%), asthma or chronic obstructive pulmonary disease (16%), and obesity (16.8%). About 15.9% of the BCS were diagnosed with depression in the year prior to, at the time of, or in the 2-year follow up period after the cancer diagnosis. With bivariate analysis, significant differences were found between BCS with and without depression: those with depression had higher mean number of hospital stays (.33 vs .11), mean number of bed days (1.94 vs .58), mean number of ambulatory visits (34.26 vs 20.42), and mean number of pharmacy prescriptions (45.49 vs 27.60). For follow up care, BCS with a diagnosis of depression cost, on average, $7174 more annually then those without a diagnosis of depression ($15,471 vs $8,297). No demographic characteristics significantly increased the likelihood of having received a diagnosis of depression. Discussion. The results show much higher annual health care utilization and costs for BCS diagnosed with depression compared to BCS without a diagnosis of depression. These findings may reflect the health care plan provided to military-related beneficiaries, a plan that has few restrictions for cancer follow up care if medically ordered. Claims data contains no information about cancer stage, a correlate of health care utilization and costs. Overall, the findings provide empirical evidence that there is a fiscal incentive to screen and manage mild symptoms prior to patients meeting diagnostic criteria for clinical depression. Assumedly, timely screening and rapid intervention will lead to improved quality of life for the patient, decreased utilization of health care resources, and cost savings for health care plans. In this respect, the findings support the 2014 ASCO recommendations regarding screening and treatment for depression and anxiety. Conversely, the data intimate that adoption of the ASCO recommendations will lead to higher costs as more individuals are positively screened and referred for treatment. Who, what, or how such services will be afforded merits sustained inquiry. The opinions expressed herein are those of the author and are not necessarily representative of the opinions or policies of the Department of Defense. Citation Format: Diana D Jeffery. Prevalence, health care utilization and costs of concomitant depression among breast cancer survivors [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr PD4-4.

Clinical evaluation of a sub-lingual vaccine for prevention of exacerbations in COPD

Background: Lower airway bacterial infection is one of the major cause for exacerbation inCOPD. Multicomponent vaccines derived from the various causative pathogens are shownto prevent the exacerbations.Aims and Objectives: The present study was carried out toevaluate the effi cacy of sublingual vaccine (Ismigen) in preventing the exacerbations inCOPD and to observe its tolerability.Materials and Methods: Twenty four COPD patientsmeeting the eligibility criteria were enrolled in the study. Ismigen was administered once aday sublingually for ten days a month for three consecutive months. They were observed over one year for exacerbations, hospitalisations, respiratory symptoms, lung function tests and adverse reactions. The mean scores of the parameters in the previous year were compared with that of the year following treatment. Students t test and Chi- square test were used for analysis. Results: The mean number of exacerbations reduced from 6.79±3.51 to 2.67±1.90 (p&lt;0.001) and the mean number of hospitalisations from 2.29±1.85 to 0.67±0.87 (p&lt;0.001). There was no significant change in the respiratory symptom score and lung function test. Mild non-serious adverse event was reported by one patient.Conclusion: The results indicated that Ismigen could be an effective and well-tolerated add on therapy in COPD to reduce the frequency and severity of exacerbations.DOI: http://dx.doi.org/10.3126/ajms.v6i4.11634 Asian Journal of Medical Sciences Vol.6(4) 2015 51-54

Effects of radium-223 dichloride (Ra-223) on risk for hospitalization and health care resource use in the phase 3 ALSYMPCA trial.

21 Background: Ra-223 is a first-in-class alpha-emitter approved for treatment (tx) of patients (pts) with castration-resistant prostate cancer and symptomatic bone metastases. In ALSYMPCA, Ra-223 significantly improved overall survival by 3.6 months vs placebo (pbo) (HR = 0.70; 95% CI, 0.58-0.83; P &lt; 0.001) and was well tolerated. To understand whether the tx benefit corresponds to differences in utilization, hospitalization and other types of health care resource use were evaluated. Methods: Data on hospitalization, nursing home visits, home health care and adult day care services use, and physician visits were captured for each pt. Tx groups were compared, based on percentage needing each type of health care resource, using Fisher’s exact test. To account for differences in each pt resource use in ALSYMPCA, the number of encounters (eg, office visits) and duration of encounters (eg, days hospitalized) were divided by observation time. The mean number and duration of encounters were compared using analysis of variance. To compare tx groups based on the rate of use per year, incidence rates and ratios were calculated using a generalized estimating equation (GEE) regression model. Results: The mean follow-up time in months for Ra-223 vs pbo was 10.0 vs 8.6. The incidence rate for Ra-223 vs pbo was 1.1 vs 1.4 (incidence rate ratio = 0.77; 95% CI, 0.62-0.95; P = 0.013). The mean number of hospitalizations and hospitalization days per year for Ra-223 vs pbo were 1.3 vs 1.7 (P = 0.020) and 8.1 vs 14.6 (P &lt; 0.001), respectively. The percentage of pts that required hospitalization was nominally lower for Ra-223 vs pbo (42.3% vs 49.0%, P = 0.062). Among pts who experienced at least one hospitalization, the mean number of hospitalization days per year for Ra-223 vs pbo pts was 19.4 vs 30.4 (P &lt; 0.001). No significant differences were found between tx groups in terms of visits or durations of time in nursing homes per year, amount of adult day care and home health care services utilized per year, and number of physician visits per year. Conclusions: Compared with pbo, Ra-223 tx resulted in a 23% reduction in incidence of hospitalizations per year and about 6.5 fewer hospitalization days per pt per year. Clinical trial information: NCT00699751.

Su1334 Metronidazole Treatment of Clostridium difficile Infection in Inflammatory Bowel Disease Is Associated With a High Risk of Treatment Failure and Recurrence

Background and aim: Coping strategies are used to manage conflicts and illness and can have adaptative or maladaptative effects on health status. Coping strategies have not been well studied in Inflammatory Bowel Disease (IBD) and their influence on the clinical course of these diseases is unknown. The aim of the study was to evaluate the influence of the use of different coping strategies on the number of emergency or unscheduled visits and hospitalisations in IBD patients. Methods:A prospective observational cohort study was designed. The cohort consisted of consecutive patients with IBD (Crohn's disease (CD) and ulcerative colitis (UC)) who attended our monographic IBD Unit. A basal demographic and clinical questionnaire was completed by all patients. Coping strategies were assessed with the Spanish version of the COPE scale. It consists of 60 items that participants rated themselves using the dispositional response format. Patients indicated how frequently they engaged in each coping behaviour on a 4-point Likert scale. The scale had 3 different global strategies: Problem-focused coping, Avoidance coping and Emotion-focused coping. In order to assess the clinical course of IBD, all emergency or unscheduled visits and hospitalisations related with IBD over a follow-up period of 18 months were recorded. The influence of coping on clinical course was analysed by multiple regression analysis. Results: 776 patients were consecutively included [364 male (46.9%), mean age 45 years, age range 18-86 years)]. 317 (40.9%) patients suffered from CD and 459 (59.1%) from UC. At baseline evaluation, the most frequently used coping strategies by IBD patients were problem-focused coping (mean: 2.72 standard deviation (SD): 0.45) and avoidance coping (mean: 2.60 SD: 0.37), and the least frequently used was emotion-focused coping (mean: 2.36, SD: 0.57). The mean number of unscheduled or emergency visits was 1.05 (SD: 1.68, range 0-14) and the mean number of hospitalizations was 0.35 (SD: 0.94, range 0-9). The use of avoidance coping strategies was a risk factor for more emergency or unscheduled visits in themultivariate analysis (B=0.027, CI95%: 0.009-0.045; p<0.005). However, none of the coping strategies were related to more hospitalizations in the multivariate model including sociodemographic and clinical variables. Conclusions: The coping strategies most used in IBD patients were problem-focused and avoidance coping. A higher use of avoidance coping strategies appears to be a risk factor for more emergency visits in the following months. Therefore, these patients would probably benefit from psychological support.

Su1333 Influence of Coping Strategies on the Clinical Course of Inflammatory Bowel Disease: A Prospective, Observational Cohort Study

Background and aim: Coping strategies are used to manage conflicts and illness and can have adaptative or maladaptative effects on health status. Coping strategies have not been well studied in Inflammatory Bowel Disease (IBD) and their influence on the clinical course of these diseases is unknown. The aim of the study was to evaluate the influence of the use of different coping strategies on the number of emergency or unscheduled visits and hospitalisations in IBD patients. Methods:A prospective observational cohort study was designed. The cohort consisted of consecutive patients with IBD (Crohn's disease (CD) and ulcerative colitis (UC)) who attended our monographic IBD Unit. A basal demographic and clinical questionnaire was completed by all patients. Coping strategies were assessed with the Spanish version of the COPE scale. It consists of 60 items that participants rated themselves using the dispositional response format. Patients indicated how frequently they engaged in each coping behaviour on a 4-point Likert scale. The scale had 3 different global strategies: Problem-focused coping, Avoidance coping and Emotion-focused coping. In order to assess the clinical course of IBD, all emergency or unscheduled visits and hospitalisations related with IBD over a follow-up period of 18 months were recorded. The influence of coping on clinical course was analysed by multiple regression analysis. Results: 776 patients were consecutively included [364 male (46.9%), mean age 45 years, age range 18-86 years)]. 317 (40.9%) patients suffered from CD and 459 (59.1%) from UC. At baseline evaluation, the most frequently used coping strategies by IBD patients were problem-focused coping (mean: 2.72 standard deviation (SD): 0.45) and avoidance coping (mean: 2.60 SD: 0.37), and the least frequently used was emotion-focused coping (mean: 2.36, SD: 0.57). The mean number of unscheduled or emergency visits was 1.05 (SD: 1.68, range 0-14) and the mean number of hospitalizations was 0.35 (SD: 0.94, range 0-9). The use of avoidance coping strategies was a risk factor for more emergency or unscheduled visits in themultivariate analysis (B=0.027, CI95%: 0.009-0.045; p<0.005). However, none of the coping strategies were related to more hospitalizations in the multivariate model including sociodemographic and clinical variables. Conclusions: The coping strategies most used in IBD patients were problem-focused and avoidance coping. A higher use of avoidance coping strategies appears to be a risk factor for more emergency visits in the following months. Therefore, these patients would probably benefit from psychological support.

Interventions to Reduce Rehospitalizations after Chronic Obstructive Pulmonary Disease Exacerbations. A Systematic Review

Approximately 20% of patients hospitalized for COPD exacerbations in the United States will be readmitted within 30 days. The Centers for Medicare and Medicaid Services has recently proposed to revise the Hospital Readmissions Reduction Program to financially penalize hospitals with high all-cause 30-day rehospitalization rates after a hospitalization for COPD exacerbation on or after October 1, 2014. To report the results of a systematic review of randomized clinical trials evaluating interventions to reduce the rehospitalizations after COPD exacerbations. Multiple electronic databases were systematically searched to identify relevant studies published between January 1966 and June 2013. Titles, abstracts, and, subsequently, full-text articles were assessed for eligibility. Each study was appraised using predefined criteria. Among 913 titles and abstracts screened, 5 studies (1,393 participants) met eligibility criteria. All studies had a primary outcome of rehospitalization at 6 or 12 months. No study examined 30-day rehospitalization as the primary outcome. Each study tested a different set of interventions. Two studies (one conducted in Canada and one conducted in Spain and Belgium) showed a decrease in all-cause rehospitalization over 12 months in the intervention group versus comparator group (mean number of hospitalizations per patient, 1.0 vs. 1.8; P = 0.01; percent hospitalized, 45 vs. 67%; P = 0.028; respectively). The only study conducted in the United States found a greater than twofold higher risk of mortality in the intervention group (17 vs. 7%, P = 0.003) but no significant difference in rehospitalizations. It was unclear which set of interventions was effective or harmful. The evidence base is inadequate to recommend specific interventions to reduce rehospitalizations in this population and does not justify penalizing hospitals for high 30-day rehospitalization rates after COPD exacerbations.

Hospitalization Resource Utilization and Costs Among Medicaid Insured Patients With Schizophrenia With Different Treatment Durations of Long-Acting Injectable Antipsychotic Therapy

This study evaluated the impact of using long-acting injectable (LAI) antipsychotics for a longer treatment duration versus a short duration on health care resource utilization among Medicaid-insured schizophrenia patients. Schizophrenia patients 13 years or older initiating LAI antipsychotics were identified from the Truven Health Analytics MarketScan Research Medicaid database between July 1, 2005, and June 30, 2010. The study population was grouped into 2 study cohorts (longer-usage-duration cohort: ≥ 180 days of supply and short-usage-duration cohort: <180 days of supply). Hospitalization-related resource utilization and costs were determined during a variable follow-up period and compared at the unadjusted and adjusted levels. Of the 5694 patients identified, 2838 patients were treated with LAI antipsychotics for a mean duration of 604 (SD, 432) days (mean age, 38.91 years), and 2856 were treated for 86 (SD, 43) days (mean age, 39.96 days). Total hospital lengths of stay, all cause (6.56 [SD, 18.63] vs 4.93 [SD, 13.40] days, P < 0.001) and schizophrenia related (5.18 [SD, 14.96] vs 4.16 [SD, 11.94] days, P = 0.005), and the mean number of hospitalizations, all cause (0.79 [SD, 1.78] vs 0.61 [SD, 1.41], P < 0.001) and schizophrenia related (0.63 [SD, 1.55] vs 0.51 [SD, 1.26], P = 0.001), were lower for the longer-usage-duration cohort. Cox regression results showed that using LAI antipsychotics for a longer duration was correlated with longer time to the first hospitalization for any cause and for schizophrenia. After multivariate regression, longer usage duration of LAI antipsychotics was associated with a decreased number of hospitalizations (-0.15 per year, P < 0.001), a decreased hospital length of stay (-1.50 days, P < 0.001), and reduced hospital payment (-26%, P < 0.001). Patients who are treated with LAI antipsychotics for a longer versus shorter duration use hospital resources less.

L-Glutamine Therapy Reduces Hospitalization for Sickle Cell Anemia and Sickle β°-Thalassemia Patients at Six Months – A Phase II Randomized Trial

Background: Increased oxidant stress plays an important role in the pathophysiology of sickle cell disease. Nicotinamide Adenine Dinucleotide (NAD) is an important anti-oxidant that protects hemoglobin as demonstrated in diseases such as methemoglobinemia. Early in-vitro studies have shown that L-glutamine, a precursor for NAD, reduced oxidant stress via improvement of NAD redox status in red blood cells.Oral administration of L-glutamine in early clinical studies supported in-vitro findings of improving NAD redox potential, therefore, a larger proof of concept clinical trial was designed and conducted. Methods: A Phase II randomized, double-blind, placebo-controlled, parallel-group, multicenter study was conducted to evaluate the safety and efficacy of L-glutamine therapy for patients 5 years or older diagnosed with sickle cell anemia or sickle β°-thalassemia. Eighty one patients were randomized (1:1 ratio) to oral L-glutamine at 0.3 g/kg or placebo twice daily for 48 weeks. The primary endpoint was the frequency of painful crises. Secondary endpoints included the frequency of hospitalization. Results: At Week 24 (6 months), the mean number of painful crises was 2.5 and 5.5 for L-glutamine and placebo groups respectively (p = 0.060). The mean number of hospitalizations was 0.8 and 1.3 for L-glutamine and placebo groups respectively (p = 0.036). Conclusion: At 6 months of therapy, L-glutamine treatment was efficacious in reducing the frequency of hospitalization (nearly 40% reduction) and there was a major trend for the decrease in frequency of painful crises (over 50% reduction) favoring the L-glutamine treatment arm. There was no difference in safety between groups. Based on these findings, a Phase III trial was conducted and results are now available.

Unité de néonatologie de référence nationale du Mali : état des lieux

The neonatal mortality rate in Mali is one of the highest in the world. Only one national reference neonatology unit is available in the country. To describe the time-course of morbidity, mortality, staff and accommodation facilities from 2008 to 2009 in Mali's unique national reference neonatology unit. This descriptive and cross-sectional study was conducted in the neonatology unit of Gabriel Touré Teaching Hospital, Bamako. Data concerning staff number of admissions, sex ratio, diseases, patients outcome, capacity and length-of-stay were compiled for the period from 1st January 2008 to 31 December 2012. Medical staff increased from one to three in 2009 and the number of nurses and midwives decreased from 16 to 14 with an average number of beds of 44. The mean number of hospitalizations per year was 3,900 (range: 3667-4585) with 14% of in-born deliveries and a mean length-of-stay of 3.7 days. Prematurity birth asphyxia and infection represented 80.5% of reasons for admission and 79.5% of deaths. The mortality rate varied from 28.5% to 36.8% with an annual mean of 33.2%. The diseases associated with the highest mortality were tetanus (60.8%), prematurity (42.7%), birth asphyxia (29.4%) and infection (25.7%). Neonatal mortality remains very high in Mali. Health authorities should take measures to decentralize the care of sick newborns in order to reduce neonatal mortality in Mali.

Long Term Safety and Efficacy Of Low Fixed Dose Hydroxyurea In Pediatric Patients With Sickle Cell Anemia: A Single Center Study From Central India

IntroductionHydroxyurea (HU) therapy ameliorates the morbidity associated with Sickle cell anemia (SCA). HU is typically escalated to maximum tolerated doses (MTD) for treatment of SCA patients. Monitoring HU for toxicity poses potential challenges in low resource settings. We have previously reported the safety and efficacy of fixed low dose HU at 10mg/kg body weight ( Jain et al 2013). We studied the long term safety and efficacy of low dose HU in pediatric patients with SCA. MethodsLong term observational follow up of 40 young Indian SCA patients was carried out for a period of 10 years in a single tertiary care center in central India. The number of clinical events including vasocclusive crises, acute chest syndrome, stroke, sequestration crises, avascular bone necrosis in the entire cohort was assessed prior to starting HU and subsequently every 3 months. Laboratory parameters including hemoglobin levels, Hb F levels, mean corpuscular volume, mean corpuscular hemoglobin concentration were also followed up over the same time period. ResultsThe total number of patients in this study was 40 (17 females & 23 males). Mean age was 12.95 years ± 9.62. All patients had HbSS. There was an increase in mean hemoglobin, HbF, MCV and MCH over time in the patient population ( Table 1). There was a decrease in the mean number of hospitalizations, vasocclusive crises, acute chest syndromes, stroke and severe anemia ( Table 2). HU was well tolerated with minimal hematological or other toxicity (Table3). Patients who experienced transient hematological, liver or renal toxicity were able to resume HU at the same dose. HU was permanently discontinued in 2 patients who had manifestations of HIV/AIDS. HU was temporarily interrupted in one patient who was receiving treatment for tuberculosis and in one patient for the duration of a normal pregnancy. There was one death attributable to severe septicemia without evidence of neutropenia after 2 years follow up. There were 3 subjects who were lost to follow up, one after 2 years follow up and remaining 2 after 5 years of follow up. Of note, patients had a high HbF level at baseline. High HbF levels at baseline, the variable relationship of HbF to disease severity and amelioration of disease in Indian patients with high HbF has been previously reported ( Jain et al 2012, Patel et al 2012, Italia et al 2009).Table 1Mean value ± S.D of Hematological parameters for patients on long term HU(n= no.of patients)Lab parametersBaseline (n=40)6 months(n=40)24 months(n=38)60 months(n=36)120 months(n=36)Hb F18.44 ± 10.5321.35 ± 9.6321.08 ± 8.5621.92 ± 8.9522.15 ± 8.74Hb (gm %)8.94 ± 1.829.29 ± 1.639.83 ± 1.749.74 ± 1.619.76 ± 1.53MCV (fl)89.27 ± 10.9892.89 ± 10.4993.31 ± 11.3393.39 ± 10.3993.36 ± 10.41MCH29.65 ± 4.4631.11 ± 4.1831.16 ± 4.3030.88 ± 3.8431.31 ± 4.15Table 2Mean number of clinical events per year ± S.D in the entire cohortClinical parametersBaseline (n=40)1 year(n=40)5 years(n=36)10 years(n=36)Hospitalizations18.34 ± 17.332.82 ± 1.252.27 ± 2.062.72 ± 2.37Vasocclusive crises13.07 ± 18.531.45 ± 0.871.65 ± 1.581.82 ± 1.81Severe anemia4.35 ± 4.310.65 ± 0.720.58 ± 0.840.62 ± 0.83Stroke0.075 ± 0.26000Sequestration crises0.075 ± 0.26000Chest syndrome0.075 ± 0.260.025 ± 0.1580.025 ± 0.1580Avascular Necrosis0.075 ± 0.260.025 ± 0.15800Table 3Toxicity Associated with HU During Study Period of 10 yearsToxicityNo. of episodesNo. of patientsANC < 500x109/L00ANC 500-1500 x109/L64Thrombocytopenia (<80 x109/L )32ALT (> 2 times upper limit of normal)85Creatinine (> upper limit of normal)22Reticulocytopenia (Absolute Reticulocyte Count < 80 x1012/L)11Hyperpigmentation33 ConclusionsLow fixed dose HU is well tolerated and is efficacious in reducing incidence of VOC, hospitalizations, severe anemia, stroke and acute chest syndrome. Low fixed dose HU may be advantageous in low resource settings because of lower toxicity and consequently less need for monitoring. There is a need for multi-center randomized comparisons of low fixed dose HU with conventional escalation of HU dose to MTD. Disclosures:Krishnamurti:GlycoMimetics, Inc.: Research Funding.

Differences in Inflammatory Bowel Disease Characteristics between Hispanics and Non-Hispanic Whites

Purpose: Inflammatory bowel disease (IBD) has not been well-studied in Hispanics, the largest minority population in the U.S. A community-based IBD cohort was identified for Community Regional Medical Center, the regional safety-net health system for the California Central Valley, with a population of which 50.9% are Hispanic. We examined potential differences in IBD characteristics between Hispanics and non-Hispanic whites (NHWs), as well as between U.S.-born and foreign-born Hispanics. Methods: A total of 1,216 possible IBD patients, between years 2000 and 2010, were identified by ICD-9 codes from our medical records database. These records were retrospectively reviewed to confirm a diagnosis of IBD and to collect epidemiologic and disease-specific data. This data was analyzed to compare differences between U.S.-born Hispanics, foreign-born Hispanics, and NHWs gender in regards to: age of diagnosis, IBD subtype, disease location, disease behavior, IBD medications, number of hospitalizations. and health insurance status. Chi-square analysis was performed for categorical data, t-test, and analysis of variance done for continuous variables. All p-values are two-sided. Results: A total of 544 IBD patients were identified; 176 were Hispanic (102 U.S.-born and 74 foreignborn). In UC, the mean age at diagnosis was younger in both U.S.-born Hispanics and foreign-born Hispanics compared to NHWs (34 vs. 35 vs. 40, respectively; p=0.018). Hispanics with UC were also predominately male gender, in both U.S.-born Hispanics and foreign-born Hispanics, at 65.1% and 71.0%, respectively, compared to NHWs at 46.9%; p <0.001. The mean number of hospitalizations in UC patients was highest in US-born Hispanics, followed by foreign-born Hispanics and NHWs (1.2 vs. 0.89 vs. 0.63; p<0.005). Immunomodulator use in UC patients was higher in NHWs than US-born and foreign-born Hispanics (29.9% vs. 9.3% vs. 6.2%, p<0.005). Biologic use in UC was also higher in the NHWs than U.S.-born and foreign-born Hispanics (7.2% vs. 0% vs. 1.6%; p<0.005). There were no significant differences in family history of IBD, smoking status, disease location, or colectomy in the UC patients. More NHWs had private health insurance compared to both U.S.-born and foreign-born Hispanics (43.3% vs. 31.4% vs. 26.6%, p<0.001) (See Table 2).Table: Table. Characteristics of patients with Crohn's Disease (CD)Conclusion: In both U.S.-born and foreign-born Hispanics, ulcerative colitis is more predominant in males and diagnosed at a younger age than NHWs. Hispanics with UC had a higher number of hospitalizations compared to NHWs, and lower immunomodulator and biologic use compared to NHWs. There are differences in IBD characteristics among Hispanics and NHWs, which may be due to genetic and/or socio-economic differences, and further studies are needed.Table: Table. Characteristics of patients with Ulcerative Colitis (UC)

GW24-e2140 Real-world resource utilisation and costs following hospitalisation of patients with heart failure and preserved ejection fraction in five regions of China

ObjectivesThere are limited data on the humanistic and economic burden of heart failure with preserved ejection fraction (HFpEF) in China. Therefore, we aimed to collect real-world data on the resource...