Median Number Of Hospitalizations Research Articles

Socio-economic position, multimorbidity, and health care utilization among Danish left ventricular assist device patients.

Increasing numbers of patients with advanced heart failure and significant comorbidity and social barriers are considered for left ventricular assist devices (LVADs). We sought to examine health care utilization post-LVAD implantation, including the influence of individual-level socio-economic position and multimorbidity. We conducted a Danish nationwide cohort study linking individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish national medical and administrative registries. Socio-economic position included cohabitation status, educational level, and employment status. Multimorbidity was defined as two or more chronic conditions from at least two chronic disease groups. Health care utilization (hospital activity, general practice activity, and redeemed medical prescriptions) within 2years post-discharge after LVAD implantation was evaluated using descriptive statistics at 0.5year intervals. We identified 119 patients discharged alive with first-time LVAD implanted between 2006 and 2018. The median age of the patients was 56.1years, and 88.2% were male. Patients were followed until heart transplantation, LVAD explantation, death, 31 December 2018, or for 2years. The median follow-up was 0.8years. The highest median use of health care services was observed 0-0.5years post-LVAD discharge compared with the subsequent follow-up intervals: 0.5-1, 1-1.5, and 1.5-2years, respectively. The median (interquartile range) number of hospitalizations was 10 (7-14), bed days 14 (9-28), outpatient visits 8 (5-12), telephone contacts with a general practitioner 4 (2-8), and total redeemed medical prescriptions 26 (19-37) within 0-0.5years post-LVAD discharge compared with the median utilization within the consecutive follow-up periods [e.g. within 0.5-1year: hospitalizations 5 (3-8), bed days 8 (4-14), outpatient visits 5 (3-8), telephone contacts 2 (0-5), and redeemed medical prescriptions 24 (18-30)]. The median use of health care services was stable from 0.5years onwards. The median number of hospitalizations and bed days was slightly higher in patients living alone with a low educational level or low employment status within 0-0.5years post-LVAD implantation. Finally, the median number of in-hospital days and redeemed prescriptions was higher among patients with pre-existing multimorbidity. Among patients who underwent LVAD implantation, health care utilization was high in the early post-LVAD discharge phase and was influenced by socio-economic position. Multimorbidity influenced the number of in-hospital days and redeemed prescriptions during the 2year follow-up.

Evaluation of opioid use disorder treatment outcomes in patients receiving split daily versus once daily dosing of buprenorphine-naloxone

IntroductionIn clinical practice, sublingual (SL) buprenorphine-naloxone is prescribed as once daily or split daily dosing for the management of opioid use disorder (OUD). Evidence is lacking that assesses how split daily buprenorphine-naloxone affects OUD outcomes. This study aims to evaluate how the dosing frequency of SL buprenorphine-naloxone impacts therapy effectiveness when treating patients with OUD. MethodsThis retrospective analysis included adult outpatients prescribed treatment with SL buprenorphine-naloxone for OUD between July 1, 2016, and March 1, 2020. The study excluded patients with sickle cell disease, recent methadone treatment, or pregnancy. We characterized study groups by dosing frequency, either once daily or split dosing. The study compared retention in treatment, medication adherence, adherence to treatment program, and hospital encounters between groups. ResultsThe study screened eight-hundred and seven patients, and included 250 patients newly prescribed SL buprenorphine-naloxone. Fifty-seven patients (22.8 %) were prescribed once daily dosing and 193 patients (77.2 %) were prescribed split daily dosing. The study found no significant differences noted in 12-month rates of treatment retention (52.6 % vs. 45.6 %, p = .35). These outcomes remained similar when assessed at three and six months. Within a year of buprenorphine-naloxone initiation, the study found no differences in the percentage of patients with hospitalizations (26.3 % vs. 38.3 %, p = .10), median number of hospitalizations (2 vs. 2), or proportion of days covered by a prescription ≥80 % (93.3 % vs. 92.0 %, p = .82). ConclusionsIn this study, patients receiving once daily buprenorphine-naloxone had similar treatment outcomes to patients receiving split dosing. Further controlled studies are necessary to evaluate which patients are more likely to benefit from split dosing.

Myelosuppression and healthcare utilization among patients with chemotherapy-treated extensive-stage small cell lung cancer (ES-SCLC) with and without trilaciclib from community oncology practices.

527 Background: Trilaciclib has been recently approved for decreasing chemotherapy-induced myelosuppression among adults with ES-SCLC when administered prior to chemotherapy in US. The objective of this study was to estimate the reduction in myelosuppression with trilaciclib use using real-world data. Methods: This study compared ES-SCLC patients receiving trilaciclib and chemotherapy (T) during Feb 2021- Jan 2023 to a comparison cohort not receiving trilaciclib (C) during Apr 2020 – Jan 2023 using EMOL Health’s database, which includes >7 million patients from > 500 community oncology practices. The C cohort was matched to the T cohort based on age, chemotherapy, and line of therapy. Index date was the date of trilaciclib initiation for the T cohort and the date of chemotherapy initiation for the C cohort. Primary outcome measures were the number of events in grade ≥3 myelosuppression (in ≥1, ≥2, 3 lineages). Poisson regression models used to estimate the reduction in risk between the groups. Descriptive statistics of grade ≥3 myelosuppression, cytopenia-related healthcare utilization, and all-cause healthcare resource utilization are presented. Results: 77 T patients and 77 C patients were identified. Demographics and baseline clinical characteristics were similar (age 69.6 vs. 70.8, female 48.1% vs. 55.8% for T and C, respectively, ECOG 0/1 63.6% and 83.1% received 1st line treatment at index for both). Median duration of index treatment was 4 cycles for both cohorts. Rates of grade ≥3 myelosuppression in ≥1, ≥2, 3 lineages were estimated to be reduced in the T by 63.4% (95% CI: 44.1% - 76.7%, p < 0.001), 90.9% (95% CI: 74.7% - 97.8%, p < 0.001), and 91.9% (95% CI: 59.1% - 99.6%, p =0.016), respectively. T patients had lower prevalence of grade ≥3 myelosuppression in ≥1, ≥2, 3 lineages (11.5% vs. 27.1%; 1.2% vs. 11.7%; 0.4% vs. 4.4% per cycle) than C patients during index treatment (Table). Cytopenia-related healthcare utilization was also lower for T patients (G-CSF use 25.9% vs. 59.0%, ESA use 3.7% vs. 5.1%, blood transfusion 1.7% vs. 8.4%, platelet transfusion 1.2% vs. 2.6% per cycle during index treatment). Number of all-cause hospitalizations per patient was 0.35 for T vs. 0.51 for C during index treatment. Among those with ≥1 hospitalizations, median number of hospitalizations was 1.0 for T and 2.0 for C during index treatment. Conclusions: Results from this study suggest that trilaciclib reduces myelosuppression and cytopenia-related healthcare utilization among patients with ES-SCLC in the real world.[Table: see text]

Current situation of the hospitalization of persons without family in Japan and related medical challenges.

This study aims to determine the approximate number of hospitalizations of persons without family and the medical challenges they encounter in hospitals across Japan. Self-administered questionnaires were mailed to 4,000 randomly selected hospitals nationwide to investigate the actual conditions and problems, decision-making processes, and use of the government-recommended Guidelines for the hospitalization of, and decision-making support for, persons without family. To identify the characteristics of each region and role of hospitals, chi-square tests were used to make separate group comparisons by hospital location and type. Responses were received from 1,271 hospitals (31.2% response rate), of which 952 hospitals provided information regarding the number of admissions of persons without family. The mean (SD) and median number of hospitalizations (approximate number per year) of patients without family was 16 (79) and 5, respectively. Approximately 70% of the target hospitals had experienced the hospitalization of a person without family, and 30% of the hospitals did not. The most common difficulties encountered during the hospitalization were collecting emergency contact information, decision-making related to medical care, and discharge support. In the absence of family members and surrogates, the medical team undertook the decision-making process, which was commonly performed according to manuals and guidelines and by consulting an ethics committee. Regarding the use of the government-recommended Guidelines, approximately 70% of the hospitals that were aware of these Guidelines responded that they had never taken any action based on these Guidelines, with significant differences by region and hospital type. To solve the problems related to the hospitalization of persons without family, the public should be made aware of these Guidelines, and measures should be undertaken to make clinical ethics consultation a sustainable activity within hospitals.

Impact of primary language on health inequities in multiple myeloma.

e18640 Background: Limited English proficiency (LEP) has been shown to exacerbate health inequities in the US due to difficulties navigating a complex health system and assimilating complicated information regarding diagnosis, and treatment. Advances in multiple myeloma (MM) care have improved clinical outcomes but added complexity to diagnosis and treatment. However, there is limited data on whether LEP impacts health inequities in MM care. We sought to assess the impact of primary language on MM care and outcomes at our safety net hospital, serving a culturally and linguistically diverse population where patients have equal access to novel agents and autologous stem cell transplant (SCT). Methods: We retrospectively studied 213 patients with newly diagnosed MM between January 1st, 2000, and December 31st, 2021. Data were extracted from electronic medical records. Patients were classified as LEP or EP based on self-reported language at the time of diagnosis. Patients were subsequently propensity matched based on age, sex, type of insurance, Charlson comorbidity index, creatinine, LDH, year of MM diagnosis, ISS stage, presence of high-risk cytogenetics, and receipt of SCT. Type of insurance was used as a surrogate for socioeconomic status. Kaplan Meier estimate and log rank tests were used to assess overall (OS) and progression free survival (PFS). Results: Of 213 patients, 75 (35.2%) had LEP, 135 (63.4%) were black, 49 (23.0%) were white, 22 (10.3%) patients were of another race, and 7 (3.3%) did not self-identify. Mean age was 63.6 (SD ± 11.4), and 114 (53.5%) patients were male. Median follow-up of the entire cohort was 56.9 months. At baseline, there were no statistically significant differences in the covariates above between LEP and EP patients except for increased incidence of diabetes mellitus in EP patients (84.0% vs. 89.1%, p 0.02). More LEP patients were inpatients at the time of diagnosis compared to EP patients (36.0% [27/ 75] versus 23.9% [33/138]). Median number of hospitalizations and ED visits in the first 6 months of diagnosis were 4 and 3 versus 1 and 2 in LEP versus EP patients, respectively. There were no differences in adjusted PFS or OS between propensity matched LEP and EP patients. Conclusions: In our cohort, there were no significant differences in demographics, clinical parameters, socioeconomic status, or transplant utilization between LEP and EP patients, which allowed us to assess the association of primary language with any observed health inequities. In a setting where all patients have access to novel treatments, SCT, patient navigators, interpreters, and social workers, there were no differences in PFS or OS. However, language barriers may explain health inequities related to later diagnosis and increased healthcare utilization. LEP patients with MM may benefit from additional language-concordant resources to improve disparities.

Heart Failure Association/European Society of Cardiology Atlas second edition: new insights into understanding the burden of heart failure.

The Heart Failure Association (HFA) of the European Society of Cardiology (ESC) is committed to improving the diagnosis and treatment of heart failure (HF) and maintaining the networks of centres dedicated to its management, education, and research. Working in alliance with the National Heart Failure Societies (NHFS), this activity of the HFA has resulted in significant initiatives over the past decade, which together have given important insights into the main differences in HF management across Europe. One of these pivotal projects is the HFA/ESC Atlas, developed in collaboration and under the rules of the whole ESC Atlas project, of the European Heart Institute in Brussels. This project is intended to provide a contemporary insight into HF epidemiology, management resources, reimbursement of guideline-directed medical therapy (GDMT) and the activities of NHFS in the ESC member countries. The first edition of the HFA Atlas survey was conducted in 2018–2019 in 42 ESC member countries.1 It covered the geographical area of Europe, Mediterranean, Middle East and some of the former Soviet Union countries, comprising a total population of over 800 million people.2 According the first edition results, the median incidence of HF was 3.20 cases per 1000 person-years and a median HF prevalence of 17.20 cases per 1000 people was reported. The median number of HF hospitalizations was 2671 per million people annually, with the median length of hospital stay of 8.5 days. Diagnostic and management resources for HF varied, with high-income ESC member countries spending substantially more resources on HF compared with middle-income countries. The survey revealed a scarcity of HF centres, since the median number of hospitals with dedicated facilities and protocols for HF management was only 1.16 per million people. At the time the survey was conducted, nearly all countries reported full or partial reimbursement of standard GDMT, except ivabradine and sacubitril/valsartan. In addition, almost all countries reported having NHFS or working groups, and almost a 50% had HF patient organizations. The first edition of the HFA-ESC Atlas underlined a heterogeneity in the epidemiology of HF, the resources available for its management and the quality of care across the ESC member countries.

Real-world, population-based study of treatments, survival and healthcare use in advanced urothelial carcinoma of the bladder.

e16538 Background: Prior single institutional studies and case series suggest that management of urothelial carcinoma of the bladder (UCB) can be highly variable across different centers. To better contextualize emerging therapies and their place in management, we aimed to characterize current population-based treatment patterns, outcomes, and healthcare resource utilization. Methods: Using real-world registries and administrative data, we analyzed a contemporary cohort of patients diagnosed with advanced UCB from 2010 to 2017 in the large province of Alberta, Canada. The study time period was selected to allow for adequate follow-up. The Kaplan-Meier method was used to plot estimates of overall survival (OS) and Cox proportional hazards model was constructed to determine the associations of clinical characteristics with outcomes. Summary statistics were used to describe healthcare resource use. Results: We included 1,146 advanced UCB patients. Median age was 73 (IQR 65-81) years, majority (78%) were men, and most (69%) had a Charlson comorbidity index of 0 to 1. Only 363 (32%) were referred, consulted with oncologists, and received palliative systemic therapy. Common regimens consisted of platinum-based doublet in the first-line (1L) setting and single-agent chemotherapy or immunotherapy in the second-line (2L) setting. Only 116 (32%) of the 1L treated patients proceeded to 2L. Median OS was 9.8 months (10.2 and 5.3 months in treated and untreated patients, respectively). After adjusting for confounders, receipt of at least one line of systemic therapy was associated with improved OS (HR 0.79, 95% CI 0.65-0.95, P = 0.011) as was urban residence with more access to oncology care (HR 0.82, 95% CI 0.73-0.92, P = 0.001). Median number of emergency department visits was 4 (IQR 2-7) per patient. Median number of hospitalizations and duration of admissions were 3 (IQR 2-5) per patient and 10 (IQR 6-16) days, respectively. Conclusions: In our population-based sample, the poor prognosis of UCB may be largely attributed to the low receipt of systemic therapy rather than the burden of comorbidities or acute care encounters. Since treatment attrition is significant, efforts to streamline referral to and consultation with oncologists at the time of metastatic diagnosis may optimize the use of appropriate systemic therapies and improve survival. This is increasingly important as novel, more effective therapies for advanced UCB are introduced into the treatment armamentarium.

Association between bronchopulmonary dysplasia and early respiratory morbidity in children with respiratory distress syndrome: a case–control study using nationwide data

Bronchopulmonary dysplasia (BPD) can cause respiratory morbidity beyond the neonatal period. We aimed to analyze the association of BPD on childhood lower respiratory illness (LRI) and asthma among patients diagnosed with respiratory distress syndrome (RDS). This case–control study analyzed data between 2002 and 2015 from a nationwide database. We included 55,066 children with RDS. Two-year LRI and asthma at ages 3 and 5 were assessed. Readmission for LRIs within 2 years of birth occurred in 53.9% and 37.9% of the BPD (n = 9470) and non-BPD (n = 45,596) cases, respectively. In the BPD group, the median number of hospitalizations, mechanical ventilation and oxygen use rates were significantly higher, while the hospitalization duration was significantly longer (P < 0.001 for all). The relative risk of BPD was 1.42 (1.39–1.45) on total readmission and 6.53 (5.96–7.15) on intensive care unit readmission. Asthma prevalence was significantly higher in BPD group (57.6% vs. 48.9% at age 3 and 44.3% vs. 38.2% at age 5, P < 0.001). In children with RDS, BPD could affect repetitive and worse LRI as an independent risk factor for respiratory morbidity during the first 2 years of life. BPD may also be a crucial risk factor for asthma in preschoolers.

Healthcare resource utilization trends in patients with acute myeloid leukemia ineligible for intensive chemotherapy receiving first‐line systemic treatment or best supportive care: A multicenter international study

ObjectivesThis retrospective chart review examined real‐world healthcare resource utilization (HRU) in patients with AML ineligible for intensive therapy who received first‐line systemic therapy or best supportive care (BSC).MethodsData were collected anonymously on patients with AML who initiated first‐line hypomethylating agents (HMA), low‐dose cytarabine (LDAC), other systemic therapy, or BSC. HRU endpoints included hospitalizations, outpatient consultations, transfusions, and supportive care.ResultsOf 1762 patients included, 46% received HMA, 11% received LDAC, 17% received other systemic therapy, 26% received BSC; median treatment durations were 118, 35, 33, and 57 days, respectively. Most patients were hospitalized, most commonly for treatment administration, transfusion, or infection (HMA 82%, LDAC 93%, other systemic therapy 83%, BSC 83%). A median number of hospitalizations were 2–6 across systemic groups and two for BSC, with median durations of 8–18 days. Transfusion rates and outpatient consultations were highest for HMA (80% and 79%) versus LDAC (57% and 53%), other systemic therapy (57% and 63%), and BSC (71% and 66%). Antivirals/antibiotics and antifungals were used more frequently than growth factors (72–92%, 34–63%, and 7–27%, respectively).ConclusionPatients with AML ineligible for intensive therapy have high HRU; novel therapies are needed to alleviate this burden.

Impact of Palliative Care in End-of-Life of Fibrotic Interstitial Lung Disease Patients.

Background: Interstitial lung disease (ILD) is associated with poor quality of life (QoL) and high symptom burden. Studies evaluating the benefits of palliative care examined mainly idiopathic pulmonary fibrosis (IPF) patients. We aim to examine the impact of palliative care on a broader group of fibrotic ILD patients. Methods: Single center retrospective cohort study comparing deceased ILD patients who received outpatient palliative care services (palliative-intervention group) against a usual care group. Results: Of 63 subjects, 26 (41%) were in the palliative-intervention group and 37 (59%) in the usual care group. Median time to palliative care referral was 8.6 (IQR .3-21.2) months. Dyspnea-related disability was greater in the palliative-intervention group [mMRC dyspnea score 3.5(IQR 2-4) vs 2(IQR 2-4), P = .039], with more patients requiring long term oxygen therapy (70% vs 30%, P < .001). There was no difference in the median number of hospitalizations or length of stay in the last 6months of life. Patients in the palliative-intervention group had a higher uptake of advance care planning (ACP) (39% vs 11%, P = .014), lower frequency of intensive care unit (ICU) admissions (5% vs 19%, P = .102) and were prescribed more opioids (96% vs 27%, P < .001) and benzodiazepines (39% vs 14%, P = .022). The palliative-intervention group experienced a longer median survival of 23.9 months (95% confidence interval [CI] 14.1-33.7) compared to the usual group (11.4months [95% CI 5.4-17.3] (log-rank test: P = .023). Male gender was a strong predictor of 1-year mortality. Conclusions: The palliative-intervention group received earlier pharmacologic intervention for symptom relief. Healthcare utilization was not increased despite greater dyspnea-related disability.

P.102: Long Term Outcomes After Fetal Pancreatic Stem Cell Transplantation in Diabetes Mellitus: Data From Unified National Electronic Health System 2014–2019

Introduction: Fetal pancreatic stem cell transplantations (FPCT) from the aborted fetuses of 16–20 weeks gestation have been approved for the treatment of diabetes mellitus (DM) in a single tertiary research and training hospital in Kazakhstan. Although the immediate short-term beneficial effect was observed, there was a lack of long-term mortality assessment and the risk of diabetes-related complications among patients receiving FPCT compared to patients receiving conventional treatment (CT). We aimed to study long-term all-cause mortality and diabetes-related complications in DM patients who underwent EPCT versus CT using large-scale administrative health data from Unified National Electronic Health System (UNEHS). Methods: The initial cohort of 102,611 patients who were admitted to the hospital with DM were identified using ICD-10 codes through UNEHS between 2014–2019. Out of them, 504 patients who underwent FPCT were defined using ICD-9 procedure codes. Mortality data and patient-related demographics were linked from the National Population Registry. Identified datasets were cross-checked with the whole UNEHS dataset (n=1,565,093 observations) to ascertain the following complications/comorbidities: coronary heart disease (CHD), stroke, retinopathy, nephropathy, neuropathy, diabetic foot, neoplasms. Based on patients’ baseline characteristics (age, sex, duration of DM, residency, ethnicity, number of hospitalizations, and type of diabetes), the cohort of FPCT patients (n=504) matched with a cohort of CT patients (n=102,611) with a 1:5 ratio by propensity score matching (PSM). The final cohort of 2847 patients (504 with EPCT vs 2,343 with CT) was further evaluated. Results: After PS matching, baseline characteristics for FPCT and CT groups did not differ. Median (IQR) age was 50.6 (41.5–57.4) years old and the median duration of diabetes accounted for 6.3 (4.7–10.7) years. The cohort consisted of 55.4% females, 75.2% Kazakhs, 85.3% of type 2 DM, and 72.2% of urban residents. The median number of hospitalizations in 2014–2019 was 3 (1–6). The results of diabetes-related events and all-cause mortality presented in table 1.In logistic regression analysis, FPCT group had 48% lower risk of all-cause death compared to CT group (Odds Ratio 0.52; 95%CI: 0.37–0.72; p-value <0.001). Also, those DM patients receiving FPCT compared to the CT group were less likely to experience CHD, diabetic retinopathy, neuropathy, and diabetic foot, however, they were more likely to have diabetic nephropathy. There was no difference between the groups in terms of stroke and cancer incidences. Survival analysis depicted in figure 1.Conclusion: Findings suggest that patients receiving FPCT had a 48% lower risk of all-cause death. We also reveal better outcomes for the FPCT group regarding CHD, retinopathy, nephropathy, neuropathy, and diabetic foot, however, the EPCT group had a higher risk of nephropathy. Further investigations involving clinical and laboratory data are warranted. This study was supported by grants from the Nazarbayev University Faculty Development Research Grant Program FDCRGP 2020–2022 (Funder Project Reference: 240919FD3913).

Venous-Thromboembolism Is Associated with Increased Healthcare Utilization in Elderly Patients with Diffuse Large B Cell Lymphoma

INTRODUCTIONLymphoma is associated with a high risk of venous-thromboembolism (VTE); we have previously shown that elderly patients with diffuse large B cell lymphoma (DLBCL) have a 6.7-fold higher risk of VTE compared to control population without a history of cancer. Given this high risk, we sought to examine the impact of VTE on healthcare utilization using Surveillance, Epidemiology, and End Results Registry (SEER) data linked with Medicare. METHODSWe identified 5,537 Medicare beneficiaries diagnosed with DLBCL at age ≥66 years between 2011 and 2015, with at least 1 year of coverage prior to diagnosis, and initiation of chemotherapy within 1 year post-diagnosis. We ascertained pre-existing comorbidities for the 1 year prior to DLBCL diagnosis. Patients were followed from DLBCL diagnosis until 1 year after cancer diagnosis, or until death, loss of continuous Part A or Part B coverage, blood or marrow transplantation, or end of study (12/31/2016), whichever came first. VTE diagnosis was based on ICD 9 and ICD 10 codes for events including deep vein thrombosis (DVT) and pulmonary embolism (PE). Hospitalizations and Outpatient VisitsTotal number of hospitalizations and outpatient visits were compared in DLBCL patients with and without VTE for 1 year after cancer diagnosis, using multivariable negative binomial regression, offset for person-months and adjusting for age at diagnosis, race/ethnicity, stage at diagnosis and number of pre-DLBCL comorbidities (0, 1, 2+). Predicted counts for hospitalizations and outpatient visits were estimated from the multivariable models. Healthcare SpendingTotal inpatient and outpatient Medicare spending and spending per visit was estimated from multivariable quantile regression, offset for person-months contributed and adjusting for age at diagnosis, race/ethnicity, stage at diagnosis, and pre-DLBCL comorbidities (0, 1, 2+). RESULTSOverall, 462 (8.3%) patients developed VTE within 1 year of diagnosis of DLBCL and 244 patients had a VTE history before lymphoma diagnosis. Patients with VTE after DLBCL diagnosis had increased number of hospitalizations compared to those without VTE at the 3, 6 and 12 month time points in the first year after cancer diagnosis (Table 1). The median number of hospitalizations in patients with VTE was 2 compared to 1 in those without VTE at 3 months (p<0.0001). Increased hospitalizations continued until 1 year after lymphoma diagnosis; median number of hospitalizations was 3 in those with VTE compared to 2 in those without VTE at 1 year (p<0.0001). This lead to $51,285 in Medicare spending for hospitalizations in those with VTE compared to $37,065 in those without VTE (excess Medicare spending of $14,220 in those with VTE) in the first year after DLBCL diagnosis (p<0.001). We found no difference in the cost per visit; the excess costs were due to increased number of hospitalizations. The excess hospitalizations in those with VTE compared to those without VTE were primarily related to admissions for cardiovascular problems that included PE and/or DVT (14% vs 5%, respectively; p<0.001).Patients with VTE also had increased outpatient visits in the first year (Table 2). Median number of outpatient visits was 17 in those with VTE compared to 14 in those without VTE at 1 year (p<0.001). Medicare spending for outpatient visits in patients with a VTE diagnosis after DLBCL was $13,851 in the first year compared to $5,863 in those without VTE ($7,988 excess in those with VTE, p<0.001). Similar to hospitalizations, there was no difference in the cost per outpatient visit and the excess costs were due to increased number of visits. Increased outpatient healthcare utilization was also noted in patients who had a history of VTE prior to DLBCL diagnosis compared to those without VTE (median number of outpatient visits: 18 vs 14, p<0.001). CONCLUSIONIn conclusion, elderly patients with DLBCL and VTE (diagnosed both before and after DLBCL diagnosis) have substantially higher healthcare utilization compared to those without VTE, resulting from both increased hospitalizations and outpatient visits in the first year after cancer diagnosis; these translate into higher Medicare spending. These findings identify a need for thromboprophylaxis in high risk patients after DLBCL diagnosis and future studies should assess cost-benefit analysis with thromboprophylaxis. [Display omitted] DisclosuresGangaraju: Alexion: Consultancy; Sanofi Genzyme: Consultancy.

Disease Burden and Pre-Transplant Health-Related Quality of Life in Pediatric Sickle Cell Disease Patients Receiving Nonmyeloablative HLA-Identical Sibling Donor Transplantation

Title: Disease Burden and Pre-transplant Health-related Quality of Life in Pediatric Sickle Cell Disease Patients Receiving Nonmyeloablative HLA-identical Sibling Donor TransplantationBackground: Sickle cell disease (SCD) is a hemoglobinopathy characterized by recurrent pain crises, severe organ damage, and reduced health-related quality of life (HRQL). Bone marrow transplantation (BMT) is a proven curative treatment for SCD that can improve both disease burden and HRQL. Despite the benefits, relatively few patients pursue a cure through BMT. The decision to receive a BMT is nuanced and likely to be influenced by a number of factors. One study by Roth et al. showed SCD patients interested in BMT had a higher HRQL than those uninterested in BMT, suggesting some variability between SCD patients pursuing transplant and the general SCD patient population. To date the factors that may affect pre-transplant HRQL of pediatric SCD patients remain unclear, particularly in the nonmyeloablative setting.Objective: To evaluate the impact of disease-burden, patient demographics, and hydroxyurea treatment on pre-transplant HRQL.Methods: Children and young adults with SCD set to receive a nonmyeloablative HLA-identical sibling donor BMT were administered HRQL surveys (PedsQL) in the six months leading up to the start of the conditioning regimen. Patients' disease history and demographic information were captured and analyzed for their relationship to HRQL. PedsQL parent surveys were used when patient surveys were unavailable. The mean difference in HRQL between groups were compared using an unpaired t test or linear regression.Results: 32 patients were enrolled onto this study. Six of the 32 patients HRQL were not included due to withdrawal, delay of transplant, or completion of the survey outside of window. The median age at the time of survey administration was 13.5 years (range 2-21). 57.7% of patients were male and 88% of patients had genotypes hemoglobin SS or Sβ 0thalassemia. 12% of patients had a history of overt stroke. 52% of patients were hospitalized while receiving HU treatment. 32% of patients received chronic blood transfusions leading up to transplant. The median number of hospitalizations in the two years leading up to transplant was 2 (range 0-10). 16.7% of patients met the AAPT diagnostic criteria for chronic pain. 75% of patients received HU treatment leading up to transplant. The median hemoglobin F percentage was 10.4. The median HRQL for all patients was 77.17 (range 36.9-98.91, SD +/- 15.99).Sickle cell genotype (P=0.88), history of overt stroke (P=0.79), hospitalization while receiving HU treatment (P=0.78), and the number of hospitalizations in the two years before transplant (P=0.39) were not associated with lower HRQL. History of chronic transfusion leading up to transplant approached statistical significance for lower HRQL (P=0.06). Older age (P=0.17) and female gender (P=0.89) were not associated with worse HRQL. Patients receiving HU treatment had significantly higher HRQL than patients not receiving HU (P=0.0034), with median PedsQL scores of 80.06 and 58.64, respectively. The date of survey administration was not associated with HRQL (P=0.40). The number of eligibility criteria met (P=0.63), chronic pain (P=0.17), total number of RBC transfusions (P=0.45), and pre-transplant hemoglobin (P=0.25) were not associated with HRQL.Discussion: Patient demographics and several markers of disease burden appear to have minimal impact on HRQL. Interestingly, the use of HU therapy was associated with significantly higher pre-transplant HRQL. The etiology of this finding is unclear given that disease burden was not associated with HRQL and warrants further investigation. The absence of association between disease burden and HRQL through current disease severity eligibility paradigms suggests that other factors may impact HRQL in SCD patients choosing a low toxicity nonmyeloablative BMT. DisclosuresNo relevant conflicts of interest to declare.

Inpatient Use and Outcomes at Children's Hospitals During the Early COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has led to changes in health care use, including decreased emergency department visits for children. In this study, we sought to describe the impact of the COVID-19 pandemic on inpatient use within children's hospitals. We performed a retrospective study using the Pediatric Health Information System. We compared inpatient use and clinical outcomes for children 0 to 18 years of age during the COVID-19 period (March 15 to August 29, 2020) to the same time frame in the previous 3 years (pre-COVID-19 period). Adjusted generalized linear mixed models were used to examine the association of the pandemic period with inpatient use. We assessed trends overall and for a subgroup of 15 medical All Patient Refined Diagnosis Related Groups (APR-DRGs). We identified 424 856 hospitalizations (mean: 141 619 hospitalizations per year) in the pre-COVID-19 period and 91 532 in the COVID-19 period. Compared with the median number of hospitalizations in the pre-COVID-19 period, we observed declines in hospitalizations overall (35.1%), and by APR-DRG (range: 8.5%-81.3%) with asthma (81.3%), bronchiolitis (80.1%), and pneumonia (71.4%) experiencing the greatest declines. Overall readmission rates were lower during the COVID-19 period; however, other outcomes, including length of stay, cost, ICU use, and mortality remained similar to the pre-COVID-19 period with some variability by APR-DRGs. US children's hospitals observed substantial reductions in inpatient admissions with largely unchanged hospital-level outcomes during the COVID-19 pandemic. Although the impact on use varied by condition, the most notable declines were related to inpatient admissions for respiratory conditions, including asthma, bronchiolitis, and pneumonia.

Impact of Bronchopulmonary Dysplasia on Early Life Respiratory Morbidity in Children with Respiratory Distress Syndrome: A Nationwide Population-Based Study

Background: Bronchopulmonary dysplasia (BPD) can cause respiratory morbidity beyond the neonatal period. We aimed to analyze the influence of BPD on childhood lower respiratory illness (LRI) and asthma among patients diagnosed with neonatal respiratory distress syndrome (RDS). Methods: This case–control study analyzed data of children born between 2002 and 2015 retrieved from a nationwide database. We included 55066 children diagnosed with RDS. Patients with major congenital anomalies or who died during the initial admission period were excluded. The main outcomes were 2-year childhood LRI and asthma at ages 3 and 5. Findings: Readmission for LRIs within 2 years of birth occurred in 53·9% and 37·9% of the BPD (n=9470) and non-BPD (n=45596) cases, respectively. In the BPD group, the median number of hospitalizations was significantly higher (2 [1–40] vs. 1 [1–29], p<0·001), hospital stay duration was significantly longer (13 [6–30] vs. 8 [5–15] days, p<0·001), mechanical ventilation (3·9% vs. 0·5%, p<0·001) and oxygen use (41·0% vs. 14·5%, p<0·001) rates were significantly higher than in the non-BPD group. The relative risk of BPD was 1.42 (95% CI, 1·39–1·45) on total readmission and 6·53 (95% CI, 5·96–7·15) on intensive care unit readmission, consistent with the subgroup analysis of very low birth weight population. Asthma prevalence in the BPD group was significantly higher (57·6% vs. 48·9% at age 3 and 44·3% vs. 38.2% at age 5, p<0·001) than in the non-BPD group, and three times higher than in the general population. Interpretation: In children with RDS, BPD could affect repetitive, prolonged, and worse LRI as an independent risk factor for respiratory morbidity during the first 2 years of life. BPD was also a crucial risk factor for asthma in preschoolers. Funding: This study was supported by a Severance Hospital Research fund for Clinical excellence (SHRC) (C-2020-0014). Declaration of Interest: All authors have no conflict of interest. Ethical Approval: This study protocol was reviewed and approved by the Institutional Review Board of Severance Hospital (approval No. 4-2019-0383). As this was an observational study without intervention and the presentation of any identifying data, the requirement for informed consent was waived.

The Heart Failure Association Atlas: Heart Failure Epidemiology and Management Statistics 2019.

The Heart Failure Association (HFA) of the European Society of Cardiology (ESC) developed the HFA Atlas to provide a contemporary description of heart failure (HF) epidemiology, resources, reimbursement of guideline-directed medical therapy (GDMT) and activities of the National Heart Failure Societies (NHFS) in ESC member countries. The HFA Atlas survey was conducted in 2018-2019 in 42 ESC countries. The quality and completeness of source data varied across countries. The median incidence of HF was 3.20 [interquartile range (IQR) 2.66-4.17] cases per 1000 person-years, ranging from ≤2 in Italy and Denmark to >6 in Germany. The median HF prevalence was 17.20 (IQR 14.30-21) cases per 1000 people, ranging from ≤12 in Greece and Spain to >30 in Lithuania and Germany. The median number of HF hospitalizations was 2671 (IQR 1771-4317) per million people annually, ranging from <1000 in Latvia and North Macedonia to >6000 in Romania, Germany and Norway. The median length of hospital stay for an admission with HF was 8.50 (IQR 7.38-10) days. Diagnostic and management resources for HF varied, with high-income ESC member countries having substantially more resources compared with middle-income countries. The median number of hospitals with dedicated HF centres was 1.16 (IQR 0.51-2.97) per million people, ranging from <0.10 in Russian Federation and Ukraine to >7 in Norway and Italy. Nearly all countries reported full or partial reimbursement of standard GDMT, except ivabradine and sacubitril/valsartan. Almost all countries reported having NHFS or working groups and nearly half had HF patient organizations. The first report from the HFA Atlas has shown considerable heterogeneity in HF disease burden, the resources available for its management and data quality across ESC member countries. The findings emphasize the need for a systematic approach to the capture of HF statistics so that inequalities and improvements in care may be quantified and addressed.

The Integration of Palliative Care in General Internal Medicine Practice (QI716)

1.Contrast our unique outpatient palliative care clinic model embedded within general internal medicine to more common models.2.Evaluate the feasibility and impact of implementing our embedded outpatient palliative clinic model. Over time outpatient palliative care has changed, extending to management of patients with chronic disease. Well-studied outpatient clinic models (particularly in heart failure and oncology) improve access and outcomes, especially if patients are referred early. However, there is a lack of data assessing the impact of embedding palliative care within general internal medicine. Our study aims to evaluate outcomes and patient satisfaction of our novel interdisciplinary palliative clinic model embedded in internal medicine at the Medical University of South Carolina (MUSC). In this pilot study, eligible patients identified from our clinic were enrolled in the study (n=76) (IRB# 94172). Research Assistants (RAs) orally consented and conducted single interviews with a subsection of 13 voluntarily recruited participants, completing the Palliative Care Clinic Questionnaire. Descriptive statistics, including medians and proportions, were employed using Excel. A total of 76 participants were enrolled in the study. Of those, 13 to date were consented for the sub-study and completed the questionnaire. In our preliminary analysis, the median time as a patient in this clinic was 3 months (n=11) and the median number of hospitalizations over the last year was 1.0 (n=13). Additionally, 92% (11/12) agreed to feeling an overall improvement in their quality of life (QOL) since becoming a patient of this clinic and 100% (11/11) agreed their symptoms had been better managed. Further, of those who had completed an advanced directive (AD), 33% (4/12) had completed their AD in this clinic. Benefits of this clinic include improvement in patient QOL, symptom management, and advance care planning. This model reaches patients with complex medical issues, even without a single overriding life-limiting illness. It highlights the feasibility of improving continuity of care with hospice transitions, assisting with psychosocial needs, and increasing palliative medicine exposure to resident physicians.

Dieulafoy's lesion as a rare cause of gastrointestinal bleeding: a single-center experience

To define the clinical characteristics of Dieulafoy’s lesion (DL),determine the localization features, and investigate endoscopic treatments and their results. This retrospective study included 20 patients who presented to the Department of Gastroenterology due to gastrointestinal (GI) bleeding between January 2015 and December 2019 and were diagnosed with DL. Age, gender, comorbidities, medications used, presentation findings, hemoglobin and hematocrit values at the time of presentation, number and type of transfusions if applied, length of hospitalization in days, mortality/survival, and endoscopic procedure parameters, including the number of procedures, localization of DL, type of bleeding stigmata, and the applied technique were recorded for all patients. Ten (50%) of the patients were women, and the mean age of all patients were 66.8±17.8 years. One or more comorbidities were present in 90% of the patients. The use of acetyl salicylic acid (ASA) was present in five (25%) patients, ASA+ clopidogrel in five (25%), warfarin in two (10%), and non-steroidal anti-inflammatory drugs in two (10%). The most common complaint was observed to be hematemesis and/or melena in 16 patients (80%). DL was most frequently seen in the stomach (n=10; 50%) where it was most commonly located in the proximal corpus (n=6; 60%). The most prevalent bleeding stigma was active bleeding, which was seen in nine (45%) patients during endoscopy. Eight (40%) patients received endoscopic treatment combined with a mechanical method, and nine (45%) patients only received a mechanical treatment (endoscopic band ligation or hemoclip). The median number of hospitalizations was five days (2-22). Transfusion was required by 13 patients (65%). The mortality rate was determined as 5%. DL should be considered especially in older patients with chronic diseases who present with recurrent GI bleeding. An endoscopic examination is the first method to be applied in the diagnosis and treatment of DL. Mechanical methods should be prioritized in endoscopic treatment.

Outcomes of patients with left ventricular assist device receiving cancer directed therapies.

e19335 Background: Left ventricular assist devices (LVAD) are increasingly utilized in advanced heart failure (HF). There is a paucity of data regarding outcomes of cancer-directed therapies (CDT) in patients with LVAD. The aim of this study was to describe outcomes in this newly identified group of patients. Methods: Institutional LVAD database review to identify patients with cancer diagnosis who had at least 6 months of follow up. Chart review to capture cancer history, CDT and high-severity complications. Results: 12 of the 588 patients who received LVAD were diagnosed with cancer and received CDT. Six patients were males, 9 African Americans and 3 Caucasians. Ischemic cardiomyopathy (CM) was the etiology of HF in 4 (33%) patients, 9 (66%) patients had non-ischemic CM (including: chemotherapy induced n = 3, idiopathic n = 3, myocarditis n = 1, sarcoidosis n = 1). Cancer diagnoses, staging and high severity complications are described in table. The median age of cancer diagnosis was 59 (41-72). The median time from LVAD placement to cancer diagnosis was 21.5 months (3-47). The median number of hospitalizations was 4 (range 1-7). Conclusions: Cancer diagnosis after LVAD placement requires a multidisciplinary approach due to high rates of adverse cardiovascular and cancer related outcomes. To the best of our knowledge this is the first report of patients with LVAD receiving chemo-immunotherapy, they did not tolerate the combination and immunotherapy was discontinued after one cycle, a larger study is required to assess safety in LVAD patients. Larger prospective studies are required to determine outcomes in this complex patient population. [Table: see text]

A Clinical Pathway Reduces Admissions for Vaso-Occlusive Pain in Sickle Cell Disease

Vaso-occlusive pain, a primary feature of sickle cell disease (SCD), leads to high acute care utilization, including frequent hospital admission. Though limited by a paucity of high quality evidence, guideline recommendations for the inpatient management of vaso-occlusive pain include rapid and continual pain assessment, early and individualized pain control, and intravenous fluid resuscitation (Yawn et. al. JAMA). However, research suggests that inpatient vaso-occlusive pain management varies significantly within institutions (Co et. al. Jt Comm J Qual Saf). Clinical pathways, which are a mechanism for increasing evidence-based management within an institution to standardize and improve quality of care, have been shown to reduce variation in vaso-occlusive pain management (Morrisey et. al. Pediatr Blood Cancer). We developed and implemented a clinical pathway for the management of vaso-occlusive pain using evidence-based interventions and expert consensus guidelines and hypothesized that it would improve clinical outcomes. The pathway was implemented as an electronic orderset and providers were educated on its use, which was voluntary. A retrospective chart review was then performed of adult patients admitted to Tulane Hospital for vaso-occlusive pain during one year prior to and following pathway implementation (344 total admissions, 112 total patients). Outcome measures were hospital length of stay (LOS), rate of 30-day readmission, median number of hospitalizations over one year prior to and after pathway implementation, and incidence of acute chest syndrome. Use of patient-controlled analgesia (PCA) and intravenous (IV) promethazine were used as surrogate measures of pathway utilization. Data were summarized in terms of medians (IRQ) for continuous outcomes (analyzed with the Wilcoxon Rank Sum Test) and percentages for categorical variables (analyzed with the Pearson's Chi-Squared Test). Following pathway implementation, we observed a statistically significant decrease in median number of admissions per patient (2 vs. 1, p=0.0027), an increase in PCA use (3.6% vs. 87.3%, p&lt;0.0001), and a decrease in IV promethazine use (78% vs. 36%, p&lt;0.0001). We observed trends toward decreased 30-day readmission (26% vs 20%, p=0.6105) and increased acute chest syndrome incidence (12% vs 18%, p=0.157), but these trends were not statistically significant. No effect was found on hospital LOS. Increased PCA use and decreased IV promethazine use suggest high pathway utilization among providers. We suspect the decrease in median admissions occurred due to improved discharge planning, primarily arranging close followup, given that lack of an outpatient provider is a known risk factor for hospital admission for vaso-occlusive pain (Brodsky Am J Med). Despite the reduction in median admissions, the observed decrease in readmission rates was not statistically significant, possibly due to insufficient study power. A nonsignificant change in readmission rates may also suggest that additional interventions need to be developed and evaluated to address socioeconomic barriers to outpatient healthcare access, such as financial insecurity and missed appointments, which have also been identified as modifiable risk factors for readmission (Cronin et. al. Hematology). The lack of an effect on hospital LOS may be due to the confounding variable of pain episode severity, which is difficult to control for given the absence of a biomarker for vaso-occlusive disease severity. Thus, we suggest 30-day readmission and total hospital days be used as primary outcome measures in future studies. By increasing evidence-based and expert consensus management of vaso-occlusive pain, clinical pathways may decrease hospital admissions for SCD patients. More research is needed to evaluate interventions to mitigate socioeconomic risk factors for readmission, which may then be incorporated into future clinical pathways to reduce readmission rates. Disclosures Debord: Stryker Orthopaedics: Consultancy, Other: ceives salary as well as is a stock holder with Stryker.