Medical Encounters Research Articles

Using machine-learning algorithms to improve imputation in the medical expenditure panel survey.

To assess the feasibility of applying machine learning (ML) methods to imputation in the Medical Expenditure Panel Survey (MEPS). All data come from the 2016-2017 MEPS. Currently, expenditures for medical encounters in the MEPS are imputed with a predictive mean matching (PMM) algorithm in which a linear regression model is used to predict expenditures for events with (donors) and without (recipients) data. Recipient events and donor events are then matched based on the smallest distance between predicted expenditures, and the donor event's expenditures are used as the recipient event's imputation. We replace linear regression algorithm in the PMM framework with ML methods to predict expenditures. We examine five alternatives to linear regression: Gradient Boosting, Random Forests, Extreme Random Forests, Deep Neural Networks, and a Stacked Ensemble approach. Additionally, we introduce an alternative matching scheme, which matches on a vector of predicted expenditures by sources of payment instead of a single total expenditure prediction to generate potentially superior matches. Study data is derived from a large federal survey. ML algorithms perform better at both prediction and matching imputation than Ordinary Least Squares (OLS), the most common prediction algorithm used in PMM. On average, the Stacked Ensemble approach that combines all the ML algorithms performs best, improving expenditure prediction R2 by 108% (0.156 points) and final imputation R2 by 227% (0.397 points). Matching on a prediction vector also improves alignment of sources of payments between donor and recipient events. ML algorithms and an alternative matching scheme improve the overall quality of expenditure PMM imputation in the MEPS. These methods may have additional value in other national surveys that currently rely on PMM or similar methods for imputation.

Descriptive analysis of emergency medical services 72-hour repeat patient encounters in a single, Urban Agency

IntroductionEmergency department unscheduled return visits within 72-h of discharge, called a “bounceback”, have been used as a metric of quality of care. We hypothesize that specific demographics and dispositions may be associated with Emergency Medical Services (EMS) 72-h bouncebacks. MethodsFor all patient encounters within one calendar year from a large, urban EMS agency, we recorded demographics (name, date of birth, race, gender), primary impression, disposition, and vital signs for EMS encounters. A bounceback was defined as a patient, identified by matching first name, last name and date of birth, with more than one EMS encounter within 72 h. We performed descriptive statistics for patients that did and did not have a subsequent bounceback using median (interquartile range) and Wilcoxon Rank Sum test for age and frequency (percent) and chi square test for gender, race and run disposition. For patients with a bounceback, we describe the frequency and percentage of EMS professional primary impressions on initial encounter. Results98,043 encounters from January 1, 2021 to December 31, 2021, were analyzed. The median age was 50 years (IQR 32–65); 49.4% (46,147) were female and 50.7% (47,376) were White patients. 3951 encounters had a subsequent bounceback, and compared to those without bouncebacks, they were more often male patients (58.7% versus 50.2%, p < 0.001) and more commonly not transported (22.3% versus 15.5%, p < 0.001). A multivariable logistic regression model estimated the odds of bounceback were lower for females [OR 0.64 (95% CI 0.61–0.68)], Asian and Latino patients compared to White patients [OR 0.33 (95% CI 0.21–0.53) and 0.42 (95% CI 0.34–0.51)], respectively, no significant difference for Black patients compared to White patients, and higher for non-transported patients [OR 1.25 (95% CI 1.16–1.34)]. The The most common EMS primary impression for initial and subsequent encounters was mental health [576 (14.7%) and 944 (17.0%), respectively]. For subsequent encounters, the primary impression was cardiac arrest or death in 67 (1.2%) of cases. ConclusionBouncebacks were common in this single year study of a high-volume urban EMS agency. Male and non-transported patients most often experienced bouncebacks. The most common primary impression for encounters with bounceback was mental health related. Out-of-hospital cardiac arrest occurred in 1 % of bounceback cases. Further study is necessary to understand the effect on patient-centered outcomes.

NARRATIVE MEDICINE AS INTERDISCIPLINARY PRACTICE

Abstract When dealing with patients who talk about their illnesses, medical doctors need to interpret the stories they hear. Also, they need to make sense of their own experiences regarding their medical encounters. Narrative and its analysis plays a central role in such processes that require empathy and self-reflection. The interdisciplinary practice of teaching medical students concepts and theories from literary studies as well as discussing literary texts with them can expand their scientific medical understanding. This paper explores the concept of narrative in the context of geriatric medical humanities and narrative medicine, looking at how narrative competence translates into medical practice. Presenting findings from a seminar on Narrative medicine at the Medical University of Graz, Austria, it also addresses some methodological and didactic challenges of this interdisciplinary approach.

SUBJECTIVE COGNITIVE DECLINE AS A PREDICTOR OF INCIDENT HOMEBOUND STATUS AMONG OLDER ADULTS

Abstract In the US, over 2 million older adults are homebound, meaning they never or rarely leave their home. Being homebound increases risk for negative outcomes, including depression and mortality. Dementia diagnosis is a risk factor for becoming homebound, but over half of those with dementia do not receive a formal diagnosis. Subjective cognitive decline (SCD)—self-reported increase in memory loss over a given timeframe—is an early indicator of dementia that can be easily determined during routine medical encounters. SCD screening could be a valuable tool for identifying older adults at risk of becoming homebound—a critical first step towards supporting these individuals and their caregivers—but its predictive value is not yet known. We examined a nationally representative sample of 4,914 (weighted n=34,381,060) community-living older adults who responded to the 2016 and 2017 National Health and Aging Trends Study (NHATS). We modelled incident homebound status as a function of SCD using weighted, multivariable logistic regression while adjusting for older adult sociodemographic characteristics, health status, and caregiving support. In adjusted models, those who reported SCD experienced 43% greater odds of becoming newly homebound from 2016-2017 (aOR: 1.43; p=0.03). This relationship persisted among individuals without a formal dementia diagnosis (n=4,735); among these individuals, those who reported SCD experienced 50% greater odds of becoming newly homebound (aOR: 1.50; p=0.02). Findings suggest the potential value of SCD screening as an efficient method of identifying older adults who may benefit from resources that reduce the risk and/or mitigate the negative effects of becoming homebound.

REAL-WORLD EFFECTIVENESS ENHANCED INFLUENZA VACCINES IN OLDER ADULTS DURING THREE CONSECUTIVE INFLUENZA SEASONS: 2017–2020

Abstract Unenhanced influenza vaccines often fail to elicit adequate immune responses in adults ≥65 years due to immunosenescence. Enhanced influenza vaccines, MF59-adjuvanted trivalent inactivated influenza vaccine (aTIV) and high-dose vaccine (HD-TIV), were specifically developed to overcome this problem. The relative vaccine effectiveness (rVE) of aTIV vs HD-TIV and standard, egg-derived quadrivalent influenza vaccines (QIVe) was estimated in 3 retrospective cohort studies during the 2017-2020 US influenza seasons. Influenza-related medical encounters (IRMEs) were identified using diagnostic codes specific to influenza disease (ICD J09*-J11*) from a dataset that integrated electronic primary care medical records with pharmacy and medical claims. rVE was estimated using propensity score methods adjusting for variables including age, sex, race, ethnicity, geographic location, week of vaccination, frailty and health status. Subgroup analyses included specific age groups and those with high-risk medical conditions. aTIV demonstrated a consistent benefit over QIVe and HD-TIV across all three seasons in the overall study populations, and greater rVE versus QIVe was consistently observed over all three seasons in all age subgroups as well (65-74, 75-84, 85+). aIIV3 was comparable to HD-TIV and more effective than QIVe in a subgroup with high-risk medical conditions. These findings lend further support to the use of aTIV to prevent influenza-related medical encounters in older individuals.

1657. Real-life implementation of a machine learning based algorithm for urinary tract infection antibiotic resistance management in the community setting

Abstract Background At outpatient visits, one of the most common reasons for antibiotics administration is Urinary Tract Infection (UTI), where selection of the appropriate empiric antibiotic requires consideration of multiple factors. The aim of this study was to assess the implementation and effectiveness of a machine learning based model for UTI antibiotic resistance, embedded in the physician's medical encounter workflow. Methods A longitudinal, nationwide prospective study, conducted by Maccabi Healthcare Services, a health organization in Israel serving 2.5 million members, with about 120,000 medical encounters with a UTI diagnosis per year. We adopted a machine-learning algorithm to predict antibiotic susceptibility using personal electronic health record data. Then, a designated order set was incorporated within our electronic health record interface, named 'UTI Smart-set' (UTIS). When a UTI diagnosis code is selected by the physician, a pop up screen emerges with the recommended antibiotics. The recommendation is based on the personal predicted susceptibility model developed, followed by the optimal narrow-spectrum antibiotic as recommended by the organizational clinical guidelines. . We analyzed the antibiotic prescriptions that were recommended by UTIS, the actual prescriptions given, and compared them to the culture results and the pathogen antibiotic resistance profile. Results From July 1st 2021 to April 1st 2022, among 73,148 medical encounters with a UTI diagnosis, 34,659 antibiotic prescriptions were provided. In 21,924 (63.2%) encounters the UTIS recommendation was accepted whereas in 12,736 (36.7%) it was declined. Use of the UTIS recommendation resulted in a 31.8% reduction of the measured resistance to antibiotics prescribed to patients, 10.9% (2,224) of cases who followed the UTIS recommendation for antibiotics versus 16.0% (1,879) case who did not. A 47% cumulative improvement in adherence to clinical guidelines was also observed using the tool. Conclusion This unique, point of care, antibiotic stewardship tool, based on a combination of clinical guidelines and personalized medicine, led to a major improvement in the selection of appropriate antibiotics. Disclosures Shirley Shapiro Ben David, MD, pfizer: Grant/Research Support.

Patients’ preference approach to overcome the moral implications of family-centred decisions in Saudi medical settings

BackgroundIn Saudi clinical settings, cultural influences can give a patient’s family authority to override the patient’s autonomous right to make informed health-related decisions. Cultural values should not prevent patients from exercising their genuine preferences when making medical decisions in their own best interests.DiscussionThis article discusses the moral implications of family-centred medical decisions for autonomous patients who are competent and capable of making decisions. The author argues that socio-cultural values do not justify the decision to override patient autonomy when patients express a preference for making their own choices.ConclusionThe author recommends the use of a model of shared decision-making that accounts for both individual and relational conceptions of autonomy, approaching patients’ preferences in all medical encounters with the aim of minimising the potential for socio-cultural values to undermine patient autonomy. Although this approach is a safeguard against both family and medical paternalism, allowance is made for clinicians to act in weakly paternalistic ways when patients at high risk of exacerbating existing medical conditions are likely to benefit from delaying or limiting the disclosure of potentially distressing but non-fatal diagnoses and prognoses. Thus, the author argues that even in a culture that supports family involvement in management decisions, physicians should respect patient autonomy by asking patients for their preferences in the disclosure of their medical diagnoses, prognoses and management options and verifying patients’ preferences about the roles they wish their families to play (if any) in health-related decisions.

Saving time, signaling trust: Using the PROMOTE self-report screening instrument to enhance prenatal care quality and therapeutic relationships.

Comprehensive screening of psychosocial vulnerabilities and substance use in prenatal care is critical to promote the health and well-being of pregnant patients. Effective implementation of new screening procedures and instruments should be accompanied by an in-depth investigation to assess their feasibility and impact on care delivery. In 2020, following implementation of the Profile for Maternal and Obstetric Treatment Effectiveness (PROMOTE) an innovative self-report screening instrument developed for outpatient prenatal clinics in the U.S., we conducted individual interviews and focus groups with twenty-two midwives, nurse practitioners, and obstetric residents focused on the PROMOTE and its impacts on care delivery. We used interpretive description for the qualitative analysis of the interviews. Five themes were identified: Guiding Time Efficiently: "The Time I Don't Have," Preventing Missed Care, Signaling Trustworthiness, Establishing Trauma-Informed Foundations, and Promoting "Honest" Patient Disclosure. Interviews suggest that patient completion of the PROMOTE before the medical encounter helps reduce previously reported barriers, is more time-effective, and makes history-taking easier. It also facilitates the patient-provider relationship. Findings offer insight into the breadth and depth of clinical impact resulting from the PROMOTE, and provide guidance for the implementation of such tools to optimize health outcomes.

Using the IMEDS distributed database for epidemiological studies in type 2 diabetes mellitus

IntroductionThis study aimed to assess data relevancy and data quality of the Innovation in Medical Evidence Development and Surveillance System Distributed Database (IMEDS-DD) for diabetes research and to evaluate comparability...

Development of Machine Learning Algorithms Incorporating Electronic Health Record Data, Patient-Reported Outcomes, or Both to Predict Mortality for Outpatients With Cancer.

Machine learning (ML) algorithms that incorporate routinely collected patient-reported outcomes (PROs) alongside electronic health record (EHR) variables may improve prediction of short-term mortality and facilitate earlier supportive and palliative care for patients with cancer. We trained and validated two-phase ML algorithms that incorporated standard PRO assessments alongside approximately 200 routinely collected EHR variables, among patients with medical oncology encounters at a tertiary academic oncology and a community oncology practice. Among 12,350 patients, 5,870 (47.5%) completed PRO assessments. Compared with EHR- and PRO-only algorithms, the EHR + PRO model improved predictive performance in both tertiary oncology (EHR + PRO v EHR v PRO: area under the curve [AUC] 0.86 [0.85-0.87] v 0.82 [0.81-0.83] v 0.74 [0.74-0.74]) and community oncology (area under the curve 0.89 [0.88-0.90] v 0.86 [0.85-0.88] v 0.77 [0.76-0.79]) practices. Routinely collected PROs contain added prognostic information not captured by an EHR-based ML mortality risk algorithm. Augmenting an EHR-based algorithm with PROs resulted in a more accurate and clinically relevant model, which can facilitate earlier and targeted supportive care for patients with cancer.

Active Duty Service Members Newly Presenting With Low Back Pain in Fiscal Year 2017: Health Care Utilization, Access to Care, and Private Sector Costs Over 2-year Follow-up.

Low back pain (LBP) has accounted for the most medical encounters every year for the past decade among Active Duty Service Members (ADSMs) of the U.S. Armed Forces. The objectives of this retrospective, descriptive study were to classify LBP by clinical category (Axial, Radicular, and Other) and duration (Acute, Subacute, and Chronic) and examine the LBP-related health care utilization, access to care, and private sector costs for ADSMs over a 2-year follow-up period. The Military Health System Data Repository was queried in fiscal year 2017 for all ADSMs (ages 18-62) with outpatient encounters documented with any of 67 ICD-10 diagnosis codes indicative of LBP. A 1-year clean period before the first (index) outpatient LBP encounter date was used to ensure no recent history of LBP care. Patients were eligible if continuously enrolled and on active duty for 1 year before and 2 years following the index visit. Patients were excluded for non-musculoskeletal causes for LBP, red flags, or acute trauma within 4 weeks of the index visit and/or systemic illness or pregnancy anytime during the clean or follow-up period. A total of 52,118 ADSMs met the inclusion criteria, and the cohort was classified by duration of LBP symptoms as Acute [17,916 (34.4%)], Subacute [4,119 (7.9%)], and Chronic [30,083 (57.7%)]. Over 2-year follow-up, 419,983 outpatient visits were recorded, with the majority occurring at MTFs [363,570 (86.6%)]. 13,237 (25.4%) of ADSMs in the total cohort were documented with no other LBP-related visits beyond their index encounter. In contrast, the Chronic cohort comprised the highest number of encounters [371,031 (89.2% of total encounters)], including 86% of imaging studies performed for LBP, and accounted for $9,986,606.17 (94.9%) of total private sector costs over the 2-year follow-up period. Interventional pain procedures ($2,983,767.50) and physical therapy ($2,298,779.07) represented the costliest categories in the private sector for the Chronic cohort, whereas Emergency Department ($283,307.43) and physical therapy ($137,035.54) encounters were the top contributors to private sector costs for the Acute and Subacute cohorts, respectively. Overall reliance on the private sector was highest for specialty care, including 10,721 (75.4%) interventional pain procedures and 306 (66.4%) spine surgeries. Uncovering current trends in health care utilization and access to care for ADSMs newly presenting with LBP is vital for timely and accurate diagnosis, as well as early intervention to prevent progression to chronic LBP and to minimize its negative impact on military readiness and quality of life. This retrospective, descriptive study highlights the burden of chronic LBP on health care utilization and costs within the Military Health System, including reliance on the private sector care, amounting to $10,524,332.04 over the study period.

Participatory research to improve medication reconciliation for older adults in the community.

Medication reconciliation, a technique that assists in aligning a care team's understanding of an individual's true medication regimen, is vital to optimize medication use and prevent medication errors. Historically, most medication reconciliation research has focused on institutional settings and transitional care, with comparatively little attention given to medication reconciliation in community settings. To optimize medication reconciliation for community-dwelling older adults, healthcare professionals and older adults must be engaged in co-designing processes that create sustainable approaches. Academic researchers, older adults, and community- and health system-based healthcare professionals engaged in a participatory process to better understand medication reconciliation barriers and co-design solutions. The initiative consisted of two participatory research approaches: (1) Sparks Innovation Studios, which synthesized professional expertise and opinions, and (2) a Community Consultation Studio with older adults. Input from both groups informed a list of possible solutions and these were ranked based on evaluative criteria of feasibility, person-centeredness, equity, and sustainability. Sparks Innovation Studios identified a lack of ownership, fragmented healthcare systems, and time constraints as the leading barriers to medication reconciliation. The Community Consultation Studio revealed that older adults often feel dismissed in medical encounters and perceive poor communication with and among providers. The Community Consultation Studio and Sparks Innovation Studios resulted in four highly-ranked solutions to improve medication reconciliation: (1) support for older adults to improve health literacy and ownership; (2) ensuring medication indications are included on prescription labels; (3) trainings and incentives for front-line staff in clinic settings to become champions for medication reconciliation; and (4) electronic health record improvements that simplify active medication lists. Engaging community representatives with academic partners in the research process enhanced understanding of community priorities and provided a practical roadmap for innovations that have the potential to improve the well-being of community-dwelling older adults.

Healthcare Resource Utilization and Costs of Relapsed or Refractory Patients with Chronic Lymphocytic Leukemia or Small Lymphocytic Lymphoma Treated with Ibrutinib

Introduction: Chronic lymphocytic leukemia (CLL) is the most common type of leukemia among adults in the United States (US). First-line (1L) treatment includes targeted treatments like the Bruton's tyrosine kinase inhibitor ibrutinib. While treatment with ibrutinib can result in durable responses and improved survival, patients who progress while on ibrutinib have been shown to have a poor prognosis. However, there is currently limited literature describing the economic burden associated with ibrutinib failure. Therefore, this study was conducted to compare the healthcare resource utilization (HRU) and costs between patients with and without relapse/refractoriness (R/R) to ibrutinib in the US. Methods: Data from Optum Clinformatics DataMartTM (01/2007-03/2020) were used to identify adult patients with ≥2 medical encounters with a diagnosis code for CLL or small lymphocytic lymphoma (SLL) on different dates, ≥1 pharmacy claim for ibrutinib therapy as a single-agent or combination therapy (first dispensing was the index date), and ≥12 months of continuous enrollment pre-index date (baseline period). Patients with a diagnosis for mantle cell lymphoma or with evidence of anticancer therapy (antineoplastic, radiation, or cell therapy) during baseline were excluded. Patients were categorized as R/R to ibrutinib if they received treatment with another antineoplastic after switching/discontinuing ibrutinib; all remaining patients were considered not R/R to ibrutinib (i.e., remained on ibrutinib for the whole observation period, restarted ibrutinib, or discontinued ibrutinib treatment without initiating a different antineoplastic). Patients who died on ibrutinib or within 6 months of discontinuation without subsequent antineoplastic therapy were excluded. All-cause and CLL/SLL-related HRU and healthcare costs incurred from the index date to the earliest of death, end of data availability or insurance coverage were evaluated and then compared in the population R/R and not R/R to ibrutinib using adjusted rate ratios for HRU and adjusted cost differences for costs. P-value and 95% confidence interval (CI) were obtained from non-parametric bootstrap procedures. Results: Among 1,126 patients treated with ibrutinib, mean age was 72.5 years and 38.8% were female. Patients had a mean Quan-Charlson Comorbidity index of 3.4. Over 1.8 years of observation, patients treated with ibrutinib had mean (SD) 0.47 (0.80) all-cause inpatient stays, 0.67 (1.50) emergency room (ER) visits, and 28.4 (18.1) outpatient visits, resulting in $148,758 (77,099) per patient-year total all-cause healthcare costs. CLL/SLL-related HRU amounted to 0.37 (0.69) inpatient stays, 0.19 (0.48) ER visits, and 12.0 (10.8) outpatient visits, resulting in $29,079 (51,165) per patient-year CLL/SLL-related medical costs. A total of 207 patients were R/R to ibrutinib (mean age: 73.4 years; 40.1% female) and 919 were not R/R to ibrutinib (mean age: 72.3 years; 38.5% female). Over a mean observation of 2.4 years (R/R) and 1.8 years (not R/R), patients R/R to ibrutinib had significantly more all-cause inpatient stays (rate ratio [95% CI] = 1.92 [1.57, 2.37]; P<0.001), ER visits (1.81 [1.31, 2.61]; P<0.001), and outpatient visits (1.51 [1.38, 1.65]; P<0.001) than patients not R/R to ibrutinib (Table). This led to $16,427 (95% CI: 4,627, 28,103) significantly higher incremental all-cause healthcare costs per patient-year in the R/R cohort versus not R/R (P=0.006). Similarly, rates of CLL/SLL-related inpatient stays (rate ratio [95% CI] =1.91 [1.51, 2.40]; P<0.001), ER visits (1.93 [1.43, 2.66]; P<0.001), and outpatient visits (1.80 [1.62, 2.02]; P<0.001) were significantly higher among patients R/R to ibrutinib versus not R/R (Table). This resulted in $38,252 (95% CI: 30,505, 48,023) significantly higher incremental CLL/SLL-related medical costs per patient-year in the R/R cohort versus not R/R (P<0.001). Conclusions: In this US real-world study, patients with CLL who were treated with ibrutinib incurred substantial HRU and costs. This burden was shown to be even larger for patients who were R/R to ibrutinib, with CLL/SLL-related healthcare resource use being nearly twice higher for R/R compared to non-R/R patients. These findings highlight the unmet treatment need for patients with CLL who are R/R to ibrutinib. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Cannabinoid Poisoning-Related Emergency Department Visits and Inpatient Hospitalizations in Kentucky, 2017 to 2019

Background and objectives: Cannabis is the most used federally illicit substance. Due to widespread medicinal use and state-level legalization, public perceptions of cannabis have shifted toward the assumption that cannabis is safe. However, cannabinoids can cause adverse medical complications that may lead people to seek treatment. This study characterized cannabinoid poisoning-related medical encounters, poisoning involving cannabinoids and other psychoactive substances, and cannabinoid poisoning-related cardiac complications. Methods: Administrative billing data for emergency department visits and inpatient hospitalizations in acute care facilities with a discharge date from January 1, 2017 to December 31, 2019 were used to characterize cannabinoid poisoning events in Kentucky, identified by ICD-10-CM diagnosis code T40.7X. Results: There were 1,490 encounters of cannabinoid poisoning; patients were primarily non-Hispanic White males, ages 15–44, who had Medicaid and lived in a metropolitan area. Of those, 31.21% involved poisoning with a second psychoactive substance, primarily stimulants and/or opioids, and 17.72% experienced a cardiac complication. Cannabinoid-polydrug poisoning was associated with inpatient treatment (χ2=199.18, p < 0.001) and cardiac complications (χ2=4.58, p < 0.001). Discussion and Conclusions: These results are consistent with other state-level data. Patients who were diagnosed with cannabis-polydrug poisoning, compared to cannabis alone poisoning, had greater odds of hospital admission and cardiac complications, and longer length of hospital stays. Scientific Significance: The health risks of cannabinoid use must be more broadly recognized, while timely and accurate data need to be shared to guide policies on cannabis access. Future research on cannabinoid poisoning should consider the involvement of other psychoactive drugs.

Development of Hypertension and Atrial Fibrillation Following Diagnosis of B-Cell Malignancies - a Retrospective Analysis of US Marketscan Insurance Claims Database

Background and objectives: Compared to the general population, patients with hematologic cancers have an increased risk of cardiovascular disease (CVD) (Strongman, 2019). Given this context, pre-existing CVD may add to the complexity of treatment decisions and patient management. Analyses were conducted to describe the burden of comorbidities and subsequent risks of hypertension (HTN) and atrial fibrillation (AF) in patients with newly diagnosed B-cell malignancies, including chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), mantle cell lymphoma (MCL), marginal zone lymphoma (MZL), or Waldenström macroglobulinemia (WM), regardless of treatment status. Methods: Adult patients from the MarketScan insurance claims database who were newly diagnosed with CLL/SLL, MCL, MZL, or WM between 2015 and 2019 were included in the analyses. The first occurrence of a medical encounter for a B-cell malignancy was used as the index date. The outcomes were new or worsening HTN or new or recurring AF, stratified by the recent history of AF and HTN. In patients without a recent history of HTN, new HTN was defined as having ≥1 HTN diagnosis code and ≥1 antihypertensive prescription record. In patients with recent history of HTN, worsening of HTN was defined as having an increase in the number or doses of antihypertensive medications or as having an inpatient/emergency department admission due to HTN. In patients without recent history of AF, new AF was defined as having ≥1 inpatient claim or ≥2 outpatient claims on different days and/or an AF diagnosis with an electrocardiogram performed on the same date or within 30 days before the visit. Recurring AF was defined as above, occurring in patients with a recent history of AF. This analysis followed patients from index date until the occurrence of HTN, AF, death, or censoring, whichever came first. Results: A total of 14,592 patients were eligible for the analysis, with a mean age of 66 years (SD=13.3), 56.7% male, and with a mean Charlson comorbidity index of 2.3 (SD=2.3). The overall incidence rate of new/worsening HTN was 1.92 per 100 person-months (95% CI=1.87, 1.98) (Table 1). In patients without recent history of HTN (n=7,692, 52.7%), the incidence rate of HTN was 1.18 per 100 person-months (95% CI=1.13, 1.23). In patients with recent history of HTN (n=6,900, 47.3%), the incidence of worsening HTN was 3.07 per 100 person-months (95% CI=2.96, 3.17), with a crude hazard ratio of 2.6 (95% CI=2.5, 2.8) compared to those without a recent history of HTN. After excluding patients on cancer therapies that have been shown to increase the risk of HTN, the new/worsening HTN incidence rate was 1.91 per 100 person-months (95% CI=1.84, 1.98; n=8,658). The overall incidence rate of new/recurring AF was 0.64 per 100 person-months (95% CI=0.61, 0.67) (Table 2). In patients without a recent history of AF (n=13,288, 91.1%), the incidence rate of AF was 0.31 per 100 person-months (95% CI=0.29, 0.33). In patients with a recent history of AF (n=1,304, 8.9%), the incidence rate of recurring AF was 19.0 per 100 person-months (95% CI=17.9, 20.2), with a crude hazard ratio of 61.3 (95% CI=56.2, 66.8) compared to patients without a recent history of AF. After excluding patients on cancer therapies that have been shown to increase the risk of AF, the new/recurring AF incidence rate was 0.64 per 100 person-months (95% CI=0.60, 0.67; n=10,496). Conclusions: The results of these analyses indicate that HTN and AF occur in a non-trivial proportion of patients with B-cell malignancies regardless of treatment status. HTN rates are nearly 3-fold higher in patients with pre-existing HTN, compared to those without it; the rate of AF is more than 60-fold higher in patients with recurring AF compared to newly diagnosed AF. The incidence rates are driven by cases in patients who have pre-existing diagnoses. These analyses highlight the importance of appropriate management of pre-existing CVD to be considered in selection of treatment regimens. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Real-World Treatment Patterns and Outcomes of Daratumumab Retreatment in Multiple Myeloma in the United States

Background: Daratumumab (Dara) combination therapy is approved in transplant ineligible newly diagnosed multiple myeloma (MM), and ongoing trials evaluating Dara in transplant eligible newly diagnosed MM may result in increased first-line (1L) use. Because Dara combinations are also approved in relapsed/refractory MM, patients may receive Dara retreatment in subsequent lines of therapy (LOTs); however, data regarding optimal sequencing and benefit of Dara retreatment are lacking. Here, we present a real-world evaluation of treatment patterns and effectiveness of retreatment with Dara-based regimens. Methods: This retrospective observational study utilized deidentified electronic health records data from the Concert AI Patient360 database, representing primarily United States community-based oncology centers. The analysis included adult patients who met the following inclusion criteria: diagnosed with MM on or after January 1, 2011 through December 31, 2021, received ≥1 LOT postdiagnosis, had no prior stem cell transplantation, and had no other primary cancer diagnosis at baseline. Within this population, patients who received treatment with Dara (1L and beyond) and subsequent retreatment with Dara (second line [2L] and beyond) were identified. 1L was defined as all MM medications used within 35 days of MM-related medication initiation. Advancement of LOT was based on regimen change and documented progression events or stem cell transplant. The primary objective was to determine the proportion of MM patients initially treated and retreated with Dara-based regimens overall and by LOT. Key secondary objectives were to determine duration of treatment (DOT) and time to next treatment (TTNT) using the Kaplan-Meier method. A maximum follow-up date was determined for each patient using activity dates from multiple data files to identify the last active date of any medical encounter. Patients without subsequent LOT or death dates were censored at the maximum follow-up. Data were reported for the overall group and by the LOT in which initial Dara treatment was received. Results: Among 2367 patients with MM who met the inclusion criteria, 713 (30%) were treated with a Dara-based regimen, of which 97 (4%) were retreated with Dara and included in the analysis. Among the 97 patients analyzed, 21 (22%) started initial Dara treatment in 1L, 38 (39%) in 2L, 23 (24%) in third line (3L), and 15 (15%) in fourth or later line (4L+). Median age at diagnosis was 61-68.5 years across these groups, and 35%-50% of patients were male. Most patients had a baseline ECOG performance status of 1-2 (61%-65% for 1L, 2L, and 3L) with the exception of 4L+ (33%), and stage 2 (20%-42%) or 3 (27%-48%) disease at diagnosis. Patients were mostly treated at community (67%-81%) vs academic centers (19%-33%). Initial treatment regimens were Dara + immunomodulatory drug (IMiD) ± proteasome inhibitor (PI) (67%), Dara + PI (21%), or Dara monotherapy (12%). Dara retreatment occurred in the LOT subsequent to the initial Dara treatment episode for 90%-100% of patients; the most common retreatment regimen was Dara + IMiD (43%), followed by Dara + IMiD + PI (33%) and Dara + PI (15%). The Table shows clinical outcomes for initial Dara treatment and retreatment episodes in the same set of patients, with data by LOT indicating the line in which initial Dara treatment was received. Among 95 Dara retreated patients who had a maximum follow-up date, median DOT was 254 days and 196 days for initial Dara treatment and retreatment episodes, respectively. Median DOT by LOT for initial Dara treatment episodes ranged from 173 days (4L+ initiation) to 288 days (1L initiation). Median DOT by LOT for Dara retreatment episodes ranged from 149 days (4L+ initiation) to 304 days (1L initiation). Median TTNT was 308 days and 457 days for initial Dara treatment and retreatment episodes, respectively. Median TTNT by LOT for initial Dara treatment episodes ranged from 286 days (4L+ initiation) to 434 days (1L initiation). Median TTNT by LOT for Dara retreatment episodes ranged from 256 days (3L initiation) to not yet reached (1L initiation). Conclusion: This analysis of real-world data from adult patients diagnosed with MM showed that DOT and TTNT for Dara retreatment episodes were reasonably long and aligned with clinical expectations for subsequent therapy, suggesting that patients continue to receive meaningful clinical benefit with Dara retreatment despite prior exposure. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Conceptualizing Health Communication and its Impact on Patient Outcomes in Oncology Outpatient Settings: A Mixed-Methods Study

ObjectivesInformed by the dual process theory of supportive message, the aim of this study is to systematically describe symptom communication, including its relationship with patient outcomes. Data SourcesThis is a mixed-methods study with an exploratory design. By examining symptom communication that occurred in oncology and hospice outpatient clinics, the qualitative phase employed conversation analysis to validate a typology of interaction patterns. The subsequent quantitative phase examined the relationship between interaction patterns and patient outcomes. ConclusionA total of 52 cancer patients’ outpatient communications with their health care providers were included in the analysis. Ten unique interaction patterns were identified and defined. Among the 10 interaction patterns, some patterns are significantly associated with critical patient outcomes, including satisfaction, health communication self-efficacy, and symptom agreement between patients and their health care providers. This study represents one of the few mixed-methods studies to examine the patterns of real outpatient symptom communications and link them to concrete patient outcomes. Implications for Nursing PracticeOur results present various interaction patterns that are commonly used in medical encounters and suggest that using some patterns affects critical patient outcomes.

The Value of Rotavirus Vaccination in Europe: A Call for Action.

The severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) pandemic has pushed many healthcare systems into crisis. High vaccine coverage amongst children reduces emergency room presentations, hospital admissions and deaths due to vaccine-preventable diseases, freeing up healthcare resources including polymerase chain reaction testing for patients with SARS-CoV-2. In Europe, rotavirus gastroenteritis leads to 75,000-150,000 hospitalisations and up to 600,000 medical encounters annually. Nevertheless, in 2022, only 18 countries in Europe (out of 38) have a publicly funded routine universal mass immunisation programme against rotavirus gastroenteritis. Evidence available in the last few years re-emphasises that rotavirus vaccines currently available in Europe are highly effective, preventing up to 96% of rotavirus-related hospitalisations in children less than 1year of age (potentially 72,000-144,000 hospitalisations Europe-wide). Long-term surveillance indicates that rotavirus vaccination does not result in an overall increase in intussusception. On the contrary, increasing evidence suggests an overall reduction in intussusception in the first 12months of life when early, high rotavirus vaccine coverage is achieved. Prevention of rotavirus gastroenteritis has marked positive impacts on parental wages and government tax revenue, with benefits extending across the whole economy. In the SARS-CoV-2 pandemic setting there is a new imperative to achieve high levels of paediatric vaccination against vaccine-preventable diseases, including rotavirus gastroenteritis. The introduction of rotavirus universal mass vaccination can be expected to reduce the number of preventable illnesses, hospitalisations and deaths caused by rotavirus gastroenteritis. Reducing vaccine-preventable diseases is particularly urgent at this time when healthcare systems are preoccupied and overwhelmed with SARS-CoV-2. Graphical abstract available for this article.

Clusters of conditions among US service members diagnosed with mild TBI from 2017 through 2019.

Many US Military Service Members (SMs) newly diagnosed with mild Traumatic Brain Injury (mTBI) may exhibit a range of symptoms and comorbidities, making for a complex patient profile that challenges clinicians and healthcare administrators. This study used clustering techniques to determine if conditions co-occurred as clusters among those newly injured with mTBI and up to one year post-injury. We measured the co-occurrence of 41 conditions among SMs diagnosed with mTBI within the acute phase, one or three months post-mTBI diagnosis, and chronic phase, one year post-mTBI diagnosis. Conditions were identified from the literature, clinical subject matter experts, and mTBI care guidelines. The presence of conditions were based on medical encounters recorded within the military health care data system. Through a two-step approach, we identified clusters. Principal component analysis (PCA) determined the optimal number of clusters, and hierarchical cluster analyses (HCA) identified the composition of clusters. Further, we explored how the composition of these clusters changed over time. Of the 42,018 SMs with mTBI, 23,478 (55.9%) had at least one condition of interest one-month post-injury, 26,831 (63.9%) three months post-injury, and 29,860 (71.1%) one year post injury. Across these three periods, six clusters were identified. One cluster included vision, cognitive, ear, and sleep disorders that occurred one month, three months, and one year post-injury. Another subgroup included psychological conditions such as anxiety, depression, PTSD, and other emotional symptoms that co-occurred in the acute and chronic phases post-injury. Nausea and vomiting symptoms clustered with cervicogenic symptoms one month post-injury, but later shifted to other clusters. Vestibular disorders clustered with sleep disorders and headache disorders one-month post-injury and included numbness and neuropathic pain one year post-injury. Substance abuse symptoms, alcohol disorders, and suicidal attempt clustered one year post-injury in a fifth cluster. Speech disorders co-occurred with headache disorders one month and one year post-injury to form a sixth cluster. PCA and HCA identified six distinct subgroups among newly diagnosed mTBI patients during the acute and chronic phases post-injury. These subgroups may help clinicians better understand the complex profile of SMs newly diagnosed with mTBI.

COVID-19 Takes Cognitive Toll on Older Patients

COVID-19 Takes Cognitive Toll on Older Patients