Mean Number Of Inpatient Days Research Articles

Nursing home geriatric rehabilitation care and interprofessional collaboration; a practice-based study

BackgroundFrailty and multimorbidity are common among patients in geriatric rehabilitation care (GRC). Proper care of these patients involves multiple professionals which requires optimal interprofessional collaboration to provide the best possible support. Interprofessional collaboration (IPC) goes beyond multi-professional collaboration. It requires professionals to think beyond the expertise of their own discipline and work on joint outcomes in which the patient is actively involved. This study describes the development of the GRC teams of an elderly care organization towards the IPC.MethodsMixed method pre-post study of 15 months. The interprofessional training program comprised team trainings, webinars, and online team sessions. Data was aggregated by administering the Extended Professional Identity Scale (EPIS) and QuickScan Interprofessional Collaboration (QS) measurements to GRC staff and by observations of the multi-professional team consultation (MPC) meetings of six GRC teams of an organization for elderly care in Drachten and Dokkum in the Netherlands. ADL independence (Barthel Index) and number of inpatient days were analyzed before and after the project.ResultsPretest healthcare professional response was 106, patients for analyses was 181; posttest response was 84, patients was 170. The EPIS shows improvement on “interprofessional belonging” (P = .001, 95%CI: 0.57–2.21), “interprofessional commitment” (P = .027, 95%CI: 0.12–1.90), and overall “interprofessional identity” (P = .013, 95%CI: 0.62 − 5.20). On the QS, all domains improved; “shared values” (P = .009, 95%CI: 0.07 − 0.47), “context” (P = .005, 95%CI: 0.08 − 0.44), “structure & organization” (P = .001, 95%CI: 0.14 − 0.56), “group dynamics & interaction” (P < .001, 95%CI: 0.18 − 0.58), and “entrepreneurship & management” (P = .039, 95%CI: 0.01 − 0.48). A qualitative analysis of the reflection responses and MPC observations indicate a shift from multi-professional to more IPC. Differences in ADL over time were not statistically significant. The mean number of inpatient days was reduced by 11.8 (P < .001, 95%CI: -17.34 - − 6.31) days.ConclusionsWithin the GRC teams, there was a shift observed to more IPC and better representation of the patient’s wishes and needs. ADL independence did not change, yet we found a statistically significant decrease in the number of inpatient days. The basis for IPC was well established, however, it remains necessary that the teams continue to develop and invest in the collaboration with each other and the patient to further improve it.

Cost of Pediatric Acute Lymphoblastic Leukemia Care in the Current Treatment Era

Introduction: Acute lymphoblastic leukemia (ALL) is the most common malignancy of childhood, with a current incidence of 3,000 cases annually. Incremental alterations in treatment over time have resulted in overall survival rates that now exceed 90%. Although minor differences exist between ALL treatment protocols from different cooperative groups, risk-stratified treatment for ALL is generally standard across the country. As more has been understood about ALL biology and outcomes, treatments have been further risk stratified to optimize outcomes for higher risk individuals while minimizing toxicities for those with more favorable disease characteristics. With the improvements in outcome for ALL, cost of care is a critical component and financial toxicity for patients and society requires evaluation.Methods: Using commercial insurance data from the OptumLabs ® Data Warehouse, a cohort of 1941 ALL patients was identified, aged 1-30 years and diagnosed between 2000 and 2017 in the United States. ALL diagnosis was confirmed based on ICD-9 and ICD-10 diagnostic codes, in combination with bone marrow and lumbar puncture procedure codes within 14 days of diagnosis. Individuals were followed up to 36 months from diagnosis. Mean monthly and cumulative costs were computed for the initial 8 months of therapy and for 36 months from diagnosis, as were mean number of inpatient and outpatient days. Costs were further broken down by the types of services provided. All results were stratified by age group (1-9 years, 10-12 years, ≥13 years) as a proxy for risk group, with the younger group most consistent with standard risk disease and the older groups indicating high risk and very high risk disease, respectively.Results: Among the 1941 identified ALL patients (1-9 years, 1233; 10-12 years, 162; ≥13 years, 546), 44% were female, 51% were white, median age at diagnosis was 6 years (interquartile range 3-14 years) and 941 of enrolled patients had continuous data through 36 months. Mean cost of care over the approximate 3 years of therapy was $537,000, with approximately 58% of costs incurred within the initial intensive 8 months of therapy. Mean cost was highest among the ≥13 year age group, both for the initial 8 months of therapy ($487,000, 95% CI $449,300-530,400)), as well as over the 36 months following diagnosis ($850,000, 95% CI $778,400-937,100) (Figure). This was reflective of the highest mean number of inpatient days among the ≥13 year age group (88.1 days over 36 months, 95% CI 82.1-94.9) compared to the 10-12 year group (73.2 days, 95% CI 64.3-85.1) and the 1-9 year group (47.5 days, 95% CI 45.2-50.9). Mean number of outpatient visits over 36 months was not significantly different between 1-9 and 10-12 year age groups but was significantly higher among the ≥13 year age group compared with the 1-9 year group. Thirty-six month survival varied by age group and was highest among the 1-9 year group (95.9%, 95% CI 94.6-97.2) compared with the 10-12 year group (90.5%, 95% CI 85-4-95.8) and the ≥13 year group (79.6%, 95% CI 75.8-83.6).Conclusions: This robust real-world cost analysis shows for the first time that the average cost of ALL care in the current treatment era, including inpatient and outpatient data, is more than $500,000. We showed that the cost of care is highest among the oldest pediatric age group, indicating increasing cost with increased therapeutic intensity. This study provides a valuable benchmark that can be used to analyze the financial toxicity of ALL therapy on patients and families and can be re-assessed over time as novel therapeutics are introduced into ALL therapy. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Differences in Time Burden across Local Therapy Strategies for Early-stage Breast Cancer.

Background:“Time burden” (time required during treatment) is relevant when choosing a local therapy option for early-stage breast cancer but has not been rigorously studied. We compared the time burden for three common local therapies for breast cancer: (1) lumpectomy plus whole-breast irradiation (Lump+WBI), (2) mastectomy without radiation or reconstruction (Mast alone), and (3) mastectomy without radiation but with reconstruction (Mast+Recon).Methods:Using the MarketScan database, we identified 35,406 breast cancer patients treated from 2000 to 2011 with these local therapies. We quantified the total time burden as the sum of inpatient days (inpatient-days), outpatient days excluding radiation fractions (outpatient-days), and radiation fractions (radiation-days) in the first two years postdiagnosis. Multivariable regression evaluated the effect of local therapy on inpatient-days and outpatient-days adjusted for patient and treatment covariates.Results:Adjusted mean number of inpatient-days was 1.0 for Lump+WBI, 2.0 for Mast alone, and 3.1 for Mast+Recon (P < 0.001). Adjusted mean number of outpatient-days was 42.9 for Lump+WBI, 42.2 for Mast alone, and 45.8 for Mast+Recon (P < 0.001). The mean number of radiation-days for Lump+WBI was 32.4. Compared with Mast+Recon (48.9 days), total adjusted time burden was 4.7 days shorter for Mast alone (44.2 days) and 27.4 days longer for Lump+WBI (76.3 days). However, use of a 15 fraction WBI regimen would reduce the time burden differential between Lump+WBI and Mast+Recon to just 10.0 days.Conclusions:Although Mast+Recon confers the highest inpatient and outpatient time burden, Lump+WBI carries the highest total time burden. Increased use of hypofractionation will reduce the total time burden for Lump+WBI.

Inpatients Costs of Cancer Treatment Among Children and Young Adults with Acute Lymphoblastic Leukemia (ALL) Treated at Specialized Cancer Centers in California

▪Introduction: We previously demonstrated that receiving all cancer treatment at specialized cancer centers (SCCs; versus community hospitals) through end of therapy is associated with better leukemia-specific survival in children (0-18 years) and young adults (YA; 19-39 years) diagnosed with ALL in California. While both age groups benefit from care at a SCC, we found only a minority of YAs (36%), compared with children (84%), received care at a SCC. Our prior findings highlight the need for these patients to be referred to and treated at SCCs, but there are potential cost differences associated with this recommendation that have not been previously examined.Methods: Using the California Cancer Registry linked to the Office of Statewide Health and Planning and Development (OSHPD) statewide hospitalization database, we identified children and YAs (19-39 years) with first primary ALL who received inpatient treatment from 1995-2014 and had at least 3 years of follow-up. Patients were classified as receiving all or part/none of their treatment at a SCC (Children's Oncology Group or National Cancer Institute-designated cancer centers for children and National Cancer Institute-designated cancer centers for YAs) within 3 years of diagnosis to capture the full time of potential primary treatment. Total charges for each admission and hospital level financial information were used to calculate costs (adjusted for inflation to 2016 US dollars) for each admission, excluding peri-partum admissions and those associated with traumatic accidents. One large health maintenance organization system in California did not report charges to OSHPD and was excluded from the analysis (13% of the patient population). In addition, patients needed to have at least 80% of charge data to be included in the primary analysis, resulting in a study population of 5,167 ALL patients. We determined the number of inpatient days and cumulative inpatient costs within 3 years of diagnosis. Mean and median costs overall and per day by age group and location of care were compared using t-tests and Kruskal Wallace tests. We conducted sensitivity analyses 1) limiting our analyses to only patients with all charge data available (n=5,118) and 2) excluding patients with stem cell transplant (n=693) to determine the impact of these factors on study findings.Results: The mean cost for children receiving all care at SCCs vs non-SCCs was $216,439 (median=$121,039) vs $191,082 (median=$84,529) (p mean = 0.008; p median = <0.001). The cost per day was higher at SCCs (mean=$2,840; median=$2,529) than non-SCCs (mean=$2,283; median=$1,865) (p mean < 0.001; p median < 0.001). In children, the mean number of inpatient days within 3 years of diagnosis was similar for those who did (n=70 days) and did not (72 days) receive all cancer care in SCCs (p=0.70). Among YAs, the mean cost for patients receiving all treatment at SCCs was $380,556 (median=$308,864) vs $346,706 (median=$241,847) at non-SCCs (p mean=0.02; p median < 0.001). The cost per day was higher at SCCs (mean=$3,730; median=$3,537) than non-SCCs (mean=$3,224; median=$2,917) (p mean < 0.001; p median < 0.001). YAs receiving all cancer care at SCCs (99 days) had a similar mean number of inpatient days to those receiving care at non-SCCs (101 days) (p=0.97). In the sensitivity analyses excluding patients receiving a transplant, the mean cost was lower at both SCCs and non-SCCs, but the differences in costs in children and YAs by location of care remained. In addition, results were similar when analyses were limited to patients with complete charge data.Conclusion: In this large, population-based cohort of pediatric and YA patients with ALL, we found that inpatient costs and number of inpatient days were higher among YAs than children with ALL. In addition, in each age group, the costs of inpatient care during the full course of therapy for primary ALL was higher in patients receiving all of their care at SCCs compared patients receiving part or none of their care at an SCC. As inpatient costs do not reflect the total burden associated with cancer care, future studies should consider how location of care impacts outpatient, emergency department and out-of-pocket costs. Given findings of better outcomes among children and YAs receiving all care at SCCs, we believe the marginal increased cost should be considered in view of the better outcomes at SCCs. DisclosuresNo relevant conflicts of interest to declare.

PCN119 - SECONDARY CARE RESOURCE UTILIZATION AND COST OF CARE AMONG FINNISH NON-SMALL CELL LUNG CANCER PATIENTS

Lung cancer is the most common cancer worldwide. In Finland, 2,500 people are diagnosed with lung cancer yearly. The majority, 80-85%, of all lung cancers are non-small cell lung cancers (NSCLC), which are commonly diagnosed at an advanced stage. In this study, we characterized secondary healthcare resource utilization and associated costs of Finnish NSCLC patients in a real-life clinical setting. The treatment lines and outcomes will also be characterized in subsequent complete analyses of Finnish NSCLC population. All adult patients with newly diagnosed NSCLC at the Hospital District of Southwest Finland between the years of 2013-2014, were included in the study. Data on resource use and costs was collected retrospectively from electronic healthcare records via the Turku Clinical Research Centre (TurkuCRC) database. Data was collected one year prior to diagnosis and one year after the diagnosis. A total of 464 NSCLC patients were included in the study. The mean number of annual outpatient visits per patient was 6.7 one year prior to diagnosis and 12.5 one year after the diagnosis. The mean number of inpatient visits during the pre-diagnosis year was 0.8 and 1.4 during the post-diagnosis year. The mean number of inpatient days per year was 3.8 and 10.0, respectively. One year prior to diagnosis the mean annual total costs of secondary care resource use were 5377€ and one year after the diagnosis 11423€. There was a clear increase in healthcare resource utilization and costs after the NSCLC diagnosis. NSCLC patients had a higher number of outpatient visits and inpatient stays during the post-diagnosis year, compared to the year before NSCLC diagnosis, which resulted over 2-fold increase in annual healthcare cost.

PHS49 - Health Utility of Hospitalized Stroke Patients in Vietnam, Comparing Early Stage to Discharge

Evidence on health utility of stroke patients at intensive care units is very limited but would be useful as an input parameter for modelling cost-effectiveness of cardiovascular prevention and care. This study aims to provide evidence on health utility of such patients at different time points after hospital admission. Stroke patients admitted into Thai Nguyen National Hospital who were able to respond in an interview were invited to participate in a survey using EQ-5D. Health utility was estimated by applying a previously published algorithm. Patients were interviewed at two time points: the 5th day after first occurrence of symptoms, and on the day of hospital discharge. Patients with both cerebral infarction and cerebral hemorrhage were excluded. 148 patients were interviewed. The mean number of inpatient days was 9.5±2.5. The mean utility of interviewed patients was 0.26 on the 5th day and 0.39 on the day of discharge. The mean difference between these two measurements was statistically significant (p=0.00). Among patients with a history of a previous stroke, the difference between the two measurements (5th day and discharge) appeared to be lower than among patients without such history, but the difference was not statistically significant (p=0.6). The difference between the two measurements was not significantly different when patients with cerebral infarction and those with cerebral hemorrhage patients were compared. However, the health utility at the day of discharge from hospital was higher among cerebral infarction patients (0.42) than among patients with cerebral hemorrhage (0.23) (p=0.001). Health utilities found among stroke patients during their stay in hospital was low as compared to other studies. Utilities in cerebral infarction patients were higher than in patients with cerebral hemorrhage. The mean utility improvement during intensive care unit was 0.13. Our results can be used for cost-effectiveness analysis of cardiovascular interventions.

Epilepsy in tuberous sclerosis patients in Sweden – Healthcare utilization, treatment, morbidity, and mortality using national register data

PurposeThis study is designed to estimate the prevalence of epilepsy associated with TSC in Sweden and to describe treatment, morbidity, and mortality of TSC patients with epilepsy. MethodsRegister data for 2004–2014 was obtained from the National Board of Health and Welfare in Sweden. Patients with TSC were identified using ICD-10 codes. Epilepsy was identified using ICD-10 codes, interventions aimed to treat epilepsy, or prescriptions for antiepileptic drugs. ResultsThe prevalence of TSC was 5.38 per 100 000 individuals. We identified 551 unique patients with TSC, of which 386 (70.1%) had epilepsy. The mean study period was 8.82 years. Antiepileptic drugs were dispensed to 97.9% of patients with epilepsy. The most prescribed antiepileptic drug was sodium valproate. Ketogenic diet was used in 6 (1.6%) patients, vagus nerve stimulation in 23 (6.0%) patients, and epilepsy surgery was performed in 25 (6.5%) patients.The mean number of outpatient visits per year was 4.70 (SD 4.17) and the mean number of inpatient days per year was 3.25 (SD 5.61). The mean number of outpatient visits per year with an ICD-10 code for epilepsy was 1.65 (SD 1.95) and the corresponding number of inpatient days was 2.06 (SD 4.50). A total of 30 patients with TSC and epilepsy died during the study period. ConclusionsThe prevalence of epilepsy in this study was in the lower range of previously reported numbers, suggesting that epilepsy may be overestimated in non-population based studies. A substantial part of the healthcare utilization was directly related to epilepsy.

Days of sick leave and inpatient care at the time of pregnancy and childbirth in relation to maternal age.

To explore whether older women differ from younger women with respect to sick leave and inpatient care at the time around their first pregnancy and delivery. This was a descriptive population-based cohort study. The study population included all 236,176 nulliparous women registered as living in Sweden who gave birth to their first singleton infant in 2006-2010. Data from nationwide Swedish registers were used. Maternal age was categorized in five-year intervals. Time was calculated in years with the delivery date as the starting point, from two years before and up to three years after delivery. Descriptive statistics were used to calculate mean values and ANOVA tables were used to obtain the 95% confidence intervals of the means. Restriction was used to reduce potential confounding. Women aged ⩾35 years had a higher annual mean number of sick leave days from two years before to one year after their delivery date compared with younger women. The range for all age categories in the year before the delivery date, including pregnancy, was 15.3-37.4 mean sick leave days. The mean number of inpatient days increased with each age category during the year after the date of delivery in the range 1.4-4.3 days. This first explorative study indicates the need for more knowledge on morbidity among older primiparous women. They had a higher number of days with sick leave and hospitalization in the year before and after their delivery date. This might reflect higher health risks during pregnancy and childbirth among older women; however, social factors and reverse causation might also be influential.

Long-Term Evaluation of the Ambulatory Geriatric Assessment: A Frailty Intervention Trial (AGe-FIT): Clinical Outcomes and Total Costs After 36 Months

ObjectiveTo compare the effects of care based on comprehensive geriatric assessment (CGA) as a complement to usual care in an outpatient setting with those of usual care alone. The assessment was performed 36 months after study inclusion. DesignRandomized, controlled, assessor-blinded, single-center trial. SettingA geriatric ambulatory unit in a municipality in the southeast of Sweden. ParticipantsCommunity-dwelling individuals aged ≥75 years who had received inpatient hospital care 3 or more times in the past 12 months and had 3 or more concomitant medical diagnoses were eligible for study inclusion. Participants were randomized to the intervention group (IG) or control group (CG). InterventionParticipants in the IG received CGA-based care for 24 to 31 months at the geriatric ambulatory unit in addition to usual care. Outcome measuresMortality, transfer to nursing home, days in hospital, and total costs of health and social care after 36 months. ResultsMean age (SD) of participants was 82.5 (4.9) years. Participants in the IG (n = 208) lived 69 days longer than did those in the CG (n = 174); 27.9% (n = 58) of participants in the IG and 38.5% (n = 67) in the CG died (hazard ratio 1.49, 95% confidence interval 1.05–2.12, P = .026). The mean number of inpatient days was lower in the IG (15.1 [SD 18.4]) than in the CG (21.0 [SD 25.0], P = .01). Mean overall costs during the 36-month period did not differ between the IG and CG (USD 71,905 [SD 85,560] and USD 65,626 [SD 66,338], P = .43). ConclusionsCGA-based care resulted in longer survival and fewer days in hospital, without significantly higher cost, at 3 years after baseline. These findings add to the evidence of CGA's superiority over usual care in outpatient settings. As CGA-based care leads to important positive outcomes, this method should be used more extensively in the treatment of older people to meet their needs.

O-098: Long-term evaluation of the Ambulatory Geriatric Assessment – a Frailty Intervention Trial (AGe-FIT) – clinical outcomes and total costs after 36 months

Objective: To compare mortality and costs of health and social care between participants with access to care based on Comprehensive Geriatric Assessment (CGA) in an out-patient care setting with a control group receiving usual care only. The comparison was done 36 months after inclusion. Methods: Randomized controlled trial. Inclusion criteria: community-dwelling, aged ≥75 years, ≥3 hospitalisations the last year and ≥3 medical diagnoses. Mean age 82.5 years. Results: A total of 208 participants in the intervention group (IG) and 174 in the control group (CG). Participants in the IG lived longer than the participants in the CG. 27.9% (n = 58) in the IG versus 38.5% (n = 67) in the CG had died. HR= 1.49; CI; 1.05-2.12; P = 0.026. Mean number of inpatient days was lower in the IG (intervention 15.1 (SD 18.4), control 21.0 (SD 25.0), P = 0.01. No differences in the overall costs between the IG and CG including costs for home-help service and nursing home. Mean cost during the 36-month period after baseline assessment expressed as USD/patient (SD) in the IG was 71905 (85560) versus 65626 (66338) in the CG: P = 0.43. Conclusion: Better survival and fewer days in hospital three years after baseline assessment without increasing costs. This strengthens the positive results of a care based on CGA not only in acute care settings but also in outpatient care. A change of to-days health care organization focused on a one organ/disease is needed to a more comprehensive and preventive care of the oldest old.

An Economic Evaluation of a Self-Care Intervention in Persons With Heart Failure and Diabetes

BackgroundPersons with concomitant heart failure (HF) and diabetes mellitus constitute a growing population whose quality of life is encumbered with worse clinical outcomes as well as high health resource use (HRU) and costs. Methods and ResultsExtensive data on HRU and costs were collected as part of a prospective cost-effectiveness analysis of a self-care intervention to improve outcomes in persons with both HF and diabetes. HRU costs were assigned from a Medicare reimbursement perspective. Patients (n = 134) randomized to the self-care intervention and those receiving usual care/attention control were followed for 6 months, revealing significant differences in the number of hospitalization days and associated costs between groups. The mean number of inpatient days was 3 with bootstrapped bias-corrected (BCa) confidence intervals (CIs) of 1.8–4.4 d for the intervention group and 7.3 d (BCa CI 4.1–10.9 d) in the control group: P = .044. Total direct HRU costs per participant were an estimated $9,065 (BCa CI $6,496–$11,936) in the intervention and $16,712 (BCa CI 8,200–$26,621) in the control group, for a mean difference of −$7,647 (BCa CI −$17,588 to $809; P = .21) in favor of the intervention, including intervention costs estimated to be $130.67 per patient. ConclusionsThe self-care intervention demonstrated dominance in lowering costs without sacrificing quality-adjusted life-years.

Effectiveness of Information Technology Aided Relapse Prevention Programme in Schizophrenia excluding the effect of user adherence: A randomized controlled trial

BackgroundA relapse prevention program called the Information Technology Aided Relapse Prevention Programme in Schizophrenia (ITAREPS) has been developed and is reported to be highly effective. However the effectiveness was influenced by user adherence to the protocol of the program, the exact effectiveness and the role of the ITAREPS have been partially uncertain. ObjectiveThe purpose of this study is to evaluate the effectiveness of the ITAREPS excluding the effect of user adherence to the protocol of the program. MethodWe attempted to perform a randomized controlled trial by the devised method with visiting nurse service. Outpatients with schizophrenia were randomized to the ITAREPS (n=22) or control group (n=23) and were observed for 12months. ResultsThe risk of rehospitalization was reduced in the ITAREPS group (2 [9.1%]) compared with the control group (8 [34.8%]) (hazard ratio=0.21, 95% CI 0.04–0.99, p=0.049; number needed to treat (NNT)=4, 95% CI 2.1–35.5). The mean number of inpatient days was significantly lower in the ITAREPS group (18.5days) compared with the control group (88.8days) (p=0.036). The ratio of the number of rehospitalizations to that of relapses was significantly lower (p=0.035) and the mean change in total BPRS scores at relapse from baseline was significantly less in the ITAREPS group (p=0.019). ConclusionsThe relapse prevention effectiveness of the ITAREPS was high, and we confirmed that the ITAREPS, i.e., detecting signs of relapse and increasing medication during the warning state, is an effective intervention during the early stages of relapse.

High readmission rates are associated with a significant economic burden and poor outcome in patients with grade III/IV acute GvHD

Graft-versus-host disease (GvHD) is a common complication following haematopoietic stem cell transplant but little is published about the impact of this condition on hospital readmission rates. We report a retrospective analysis of readmission rates and associated costs in 187 consecutive allogeneic transplant patients to assess the impact of GvHD. The overall readmission rate was higher in patients with GvHD (86% (101/118) vs. 59% (41/69), p < 0.001). The readmission rate was higher both in the first 100 d from transplant (p = 0.02) and in the first year following transplant (p < 0.001). 151/455 (33%) of all readmission episodes occurred within 100 d of transplant. The mean number of inpatient days was significantly higher in patients with grade III/IV acute GvHD (101 d) compared with those with grade I/II GvHD (70 d; p = 0.003). The mean cost of readmission was higher in patients with GvHD (£28 860) than in non-GvHD patients (£13 405; p = 0.002) and in patients with grade III/IV GvHD (£40 012) compared with those patients with grade I/II GvHD (£24 560; p = 0.038). Survival was higher in those with grade I/II GvHD (55%) compared to grade III/IV GvHD (14%; p < 0.001). This study shows the high economic burden and poor overall survival associated with grade III/IV GvHD.

Living Through Distress: A Skills Training Group for Reducing Deliberate Self-Harm

Dialectical Behaviour Therapy (DBT) is an evidence-based treatment effective in reducing deliberate self-harm. However, DBT is resource and time intensive, and few services are able to sustain a programme faithful to all aspects. Thus, modified or adapted versions of DBT have been developed, particularly for delivery in inpatient hospital settings. This study presents a description of the "Living Through Distress" (LTD) Group, which is based on the group skills training component of DBT. Participants (n = 114) were patients of a psychiatric hospital who attended the LTD group. The main inclusion criterion for the LTD group was a history of deliberate self-harm. The outcome measures were frequency of incidents of deliberate self-harm, levels of distress tolerance, and mean numbers of bed days per year. Upon completion of the group, there were significant reductions in participants' reports of deliberate self-harm and significant increases in their distress tolerance levels, which were maintained at 3-month follow-up. There was also a reduction in participants' mean number of inpatient days at 1-year and 2-year follow-up. Over 50% of participants had no admissions in the year subsequent to completing the group. As this study was not a randomized controlled trial, results must be interpreted with caution. However, the findings presented here are promising, and suggest that a briefer, less resource intense version of the group skills training component of DBT may be effective in reducing deliberate self-harm.

Abstract P112: End-of-Life Care in Heart Failure: Differences Between the U.S. and Canada

Background: Heart failure (HF) is a debilitating and chronic condition with high mortality, yet little is known about costs of care at the end of life and how they differ between the US and Canada. The objective was to compare health care resource use during the last six months of life between the US and Canada among elderly patients with HF. Methods: We used a 5% national sample of Medicare beneficiaries with HF (age 65+) who died from 2000-2006 and patients in the Alberta Cardiac Access Collaborative Heart Failure cohort (age 65+) who died from 2000-2006. We tallied all-cause hospitalizations, intensive care unit (ICU) days, outpatient physician visits, and the use of tests and procedures in the 180 days preceding death. We examined the level of care at the time of death. We assessed trends over time within each country and, among patients who died in 2006, we directly compared end of life care between countries. Results: The cohort included 204,520 Medicare beneficiaries and 33,144 patients in the province of Alberta, Canada. The average age at death was 83 in both countries. The proportion of US patients hospitalized in the last six months of life was constant at 81% over the study period. In Canada, by contrast, the proportion hospitalized decreased from 84% in 2000 to 76% in 2006 (p&lt;.001). Resource use at the end of life differed between the countries ( Table ). The mean number of inpatient days was higher in Canada, but mean ICU days were higher in the US. The use of most tests and procedures was higher in the US. Patients in Canada were more likely to die in the hospital, but US. patients were more likely to be in the ICU during the terminal hospitalization. Conclusion: There are substantial differences in the management of heart failure patients in the US and Canada in the last six months of life. Further research is needed to understand the role of patient and provider preferences in the observed cross-country differences. End of Life Resource Use among HF Patients in the US and Canada, 2006 US (n=26 550) Canada (n = 4857) p-value Resource use in the 180 days preceding death Any hospitalization 21 540 (81) 3703 (76) &lt;.001 Inpatient days, mean (SD) 21 (22) 34 (35) &lt;.001 ICU days, mean (SD) 4.4 (9.3) 1.5 (7.0) &lt;.001 Stress test, no. (%) 1568 (5.9) 70 (1.4) &lt;.001 Cardiac catheterization no. (%) 1536 (5.8) 167 (3.4) &lt;.001 CABG no. (%) 348 (1.3) 39 (0.8) 0.003 Inpatient at time of death, no. (%) 9491 (35.7) 2622 (54.0) &lt;.001 ICU, no. (%) 4563 (48.1) 546 (12.1) &lt;.001

Economic Evaluation of the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) Randomized Controlled Trial

Background— Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) assigned 2331 outpatients with medically stable heart failure to exercise training or usual care. We compared medical resource use and costs incurred by these patients during follow-up. Methods and Results— Extensive data on medical resource use and hospital bills were collected throughout the trial for estimates of direct medical costs. Intervention costs were estimated using patient-level trial data, administrative records, and published unit costs. Mean follow-up was 2.5 years. There were 2297 hospitalizations in the exercise group and 2332 in the usual care group ( P =0.92). The mean number of inpatient days was 13.6 (standard deviation [SD], 27.0) in the exercise group and 15.0 (SD, 31.4) in the usual care group ( P =0.23). Other measures of resource use were similar between groups, except for trends indicating that fewer patients in the exercise group underwent high-cost inpatient procedures. Total direct medical costs per participant were an estimated $50 857 (SD, $81 488) in the exercise group and $56 177 (SD, $92 749) in the usual care group (95% confidence interval for the difference, $−12 755 to $1547; P =0.10). The direct cost of exercise training was an estimated $1006 (SD, $337). Patient time costs were an estimated $5018 (SD, $4600). Conclusions— The cost of exercise training was relatively low for the health care system, but patients incurred significant time costs. In this economic evaluation, there was little systematic benefit in terms of overall medical resource use with this intervention. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00047437.

Outcomes of Staphylococcus aureus Infection in Hemodialysis-Dependent Patients

Staphylococcus aureus is a leading cause of infection in patients with ESRD. Clinical and economic outcomes associated with S. aureus bacteremia and other S. aureus infections in patients with ESRD were examined. Laboratory, clinical, and hospital billing data from a randomized trial of 3359 hemodialysis-dependent patients hospitalized with S. aureus infection in the United States whose vascular access type was fistula or graft and who were hospitalized with S. aureus infection to evaluate inpatient costs, hospital days, and mortality over 12 wk were used. Generalized linear regression was used to identify independent predictors of 12-wk costs, inpatient days, and mortality. Of the 279 patients (8.3%) who developed S. aureus infection during approximately 1 yr of follow-up, 25.4% were treated as outpatients. Among patients for whom billing data were available, 89 patients hospitalized with S. aureus bacteremia incurred mean 12-wk inpatient costs of $19,454 and 11.9 inpatient days. Among the 70 patients hospitalized with non-bloodstream S. aureus infections, mean inpatient costs were $19,222 and the mean number of inpatient days was 11.3. Twelve-week mortality was 20.2 and 15.7% for patients with S. aureus bloodstream and non-bloodstream infections, respectively. Older age was independently associated with higher risk of death among patients with S. aureus bacteremia and with higher inpatient costs and more hospital days among patients with non-bloodstream infections. Hemodialysis-dependent patients with fistula or graft access incur high costs and long inpatient stays when hospitalized for S. aureus infection.

Diagnostic Classifications and Resource Utilization of Decedents Served by the Department of Veterans Affairs

Given the volume and cost of inpatient care during the last year of life, there is a critical need to identify patterns of dying as a means of planning end-of-life care services, especially for the growing number of older persons who receive services from the Veterans Health Administration (VHA). A retrospective computerized record review was conducted of 20,933 VHA patients who died as inpatients between October 1, 2001 and September 30, 2002. Diagnoses were aggregated into one of five classification patterns of death and analyzed in terms of health care resource utilization (mean number of inpatient days and cumulative outpatient visits in the year preceding the patient's death). Cancer deaths were the most common (30.4%) followed by end-stage renal disease (ESRD) (23.2%), cardiopulmonary failure (21.4%), frailty (11.6%), "other" diagnoses (7.3%), and sudden deaths (6.1%). Those with ESRD were more likely to be male and nonwhite (p < 0.05) and those with frailty were more likely to be older and married (p < 0.05). Controlling for demographic variables, those with frailty had the highest number of inpatient days while those with ESRD had the highest number of outpatient visits. Non-married status was associated with more inpatient days, especially among younger decedents. As a recognized leader in end-of-life care, the VHA can play a unique role in the development of specific interventions that address the diverse needs of persons with different dying trajectories identified through this research.

Quality indicators for end-of-life breast cancer care: Testing the use of administrative databases

6066 Background: Defining, measuring and monitoring quality of care is a facet of health services research that is growing in importance. Breast cancer offers a disease model to examine quality end-of-life (EOL) care provided to women. Administrative data have the unique potential to provide population-based measures of quality of care. The objective of this study was to assess the feasibility of using routinely-collected administrative data to measure quality EOL care for breast cancer patients. Methods: A cohort of all women in Nova Scotia who died of breast cancer between 01/01/1998 and 31/12/2002 was assembled from the Cancer Registry and Vital Statistics data. The EOL study period was defined as the last 6 months of life. A total of 864 women met the eligibility criteria. After a literature review, an expert panel identified 19 indicators that were potentially measurable through administrative data. Physician billings, hospital discharge abstracts and seniors pharmacare data, supplemented by clinical datasets, were utilized to calculate the statistics with which to represent the indicators. Results: Benchmark measures of care across the cohort show 63.4% died in a hospital, a mean continuity of care index of 0.786, and the mean number of inpatient days in the last 30 was 9.9. Indicators of aggressive care include 9.3% had chemotherapy in the last 14 days, 5.6% had more than 1 emergency room visit in the last 30 days, and 29.1% had more than 14 inpatient days in the last 30 days. Conclusions: Weaknesses of using these data include: 1) fixed variables with an administrative rather than a clinical objective; 2) lack of comprehensiveness of various datasets; and 3) the use of billings data where increasingly physicians are paid through methods other than fee-for-service. Strengths of this approach are: 1) population-based cohort; 2) comprehensiveness of cohort selection through the provincial Vital Statistics file; and 3) accessibility of data. No significant financial relationships to disclose.

Controlled Evaluation of a Care Pathway for An Acute Episode of Schizophrenia

Background: Care pathways have been produced for medical and surgical patients with some evidence that standards of care can be improved. This paper evaluates the use of a care pathway for the treatment of patients with an acute episode of schizophrenia. Aims: The aim of the study was to evaluate the use of a care pathway for the treatment of patients with schizophrenia. Method: A multidisciplinary team drew up and piloted a care pathway for schizophrenia. The final care pathway involved 45 standards for the acute and stabilisation phases of a schizophrenic illness. The pathway was implemented in six adult clinical teams. Outcomes for patients being treated on the care pathway were compared with a control group of patients with schizophrenia being cared for in six teams not implementing the pathway. Results: There were few significant differences in the care received between the two groups. There were no differences in terms of clinical outcome as measured by the Brief Psychiatric Rating Scale, the Clinical Global Impression, or the Camberwell Assessment of Need. There was also no difference in the mean number of inpatient days between the two groups. Conclusion: The care pathway for an acute episode of schizophrenia did not result in significant changes for patients either in terms of care received or in terms of clinical outcome.