Multicenter Healthcare System Research Articles

Healthcare Disparities Correlated with In-Hospital Mortality in COVID-19 Patients.

IntroductionIncreasing age, male gender, African American race, and medical comorbidities have been reported as risk factors for COVID-19 mortality. We aimed to identify health-care disparities associated with increased mortality in COVID-19 patients.MethodsWe performed an observational study of all hospitalized patients with SARS-CoV2 infection from within the largest multicenter healthcare system in Southeast Michigan, from February to December, 2020.ResultsFrom 11,304 hospitalized patients, 1295 died, representing an in-hospital mortality rate of 11.5%. The mean age of hospitalized patients was 63.77 years-old, with 49.96% being males. Older age (AOR = 1.05, p < 0.0001), male gender (AOR = 1.43, p < 0.0001), divorced status (AOR = 1.25, p = 0.0256), disabled status (AOR = 1.42, p = 0.0091), and homemakers (AOR = 1.96, p = 0.0216) were significantly associated with in-hospital mortality.ConclusionOlder age, male gender, divorced and disabled status and homemakers were significantly associated with in-hospital mortality if they developed COVID-19. Further research should aim to identify the underlying factors driving these disparities in COVID-19 in-hospital mortality.

Population Decline in COPD Admissions During the COVID-19 Pandemic Associated with Lower Burden of Community Respiratory Viral Infections

BackgroundThe Coronavirus disease 2019 (COVID-19) pandemic has led to widespread implementation of public health measures, such as stay-at-home orders, social distancing, and masking mandates. In addition to decreasing spread of severe acute respiratory syndrome coronavirus 2, these measures also impact the transmission of seasonal viral pathogens, which are common triggers of chronic obstructive pulmonary disease (COPD) exacerbations. Whether reduced viral prevalence mediates reduction in COPD exacerbation rates is unknown. MethodsWe performed retrospective analysis of data from a large, multicenter health care system to assess admission trends associated with community viral prevalence and with initiation of COVID-19 pandemic control measures. We applied difference-in-differences analysis to compare season-matched weekly frequency of hospital admissions for COPD prior to and after implementation of public health measures for COVID-19. Community viral prevalence was estimated using regional Centers for Disease Control and Prevention test positivity data and correlated to COPD admissions. ResultsData involving 4422 COPD admissions demonstrated a season-matched 53% decline in COPD admissions during the COVID-19 pandemic, which correlated to community viral burden (r = 0.73; 95% confidence interval, 0.67-0.78) and represented a 36% greater decline over admission frequencies observed in other medical conditions less affected by respiratory viral infections (incidence rate ratio 0.64; 95% confidence interval, 0.57-0.71, P < .001). The post-COVID-19 decline in COPD admissions was most pronounced in patients with fewer comorbidities and without recurrent admissions. ConclusionThe implementation of public health measures during the COVID-19 pandemic was associated with decreased COPD admissions. These changes are plausibly explained by reduced prevalence of seasonal respiratory viruses.

Stent Graft Oversizing is Associated with an Increased Risk of Long-Term Left Ventricular Wall Thickening in Young Patients Following Thoracic Endovascular Aortic Repair

Left ventricular (LV) wall thickening occurs in patients following thoracic endovascular aortic repair (TEVAR). Clinical consequences of cardiovascular (CV) remodeling may be more significant younger patients with longer anticipated life spans. Risk factors for CV remodeling following TEVAR are unknown but may be related to graft size. A retrospective analysis was performed of a multicenter healthcare system including patients aged ≤60 who underwent TEVAR between 2011 and 2019 with at least 1 year follow-up computed tomography angiography imaging available. Standard perioperative variables, native aortic diameter, and stent graft specifications were collected. Graft oversizing was calculated by dividing proximal graft diameter by proximal aortic diameter on preoperative imaging. Posterior LV wall thickness was measured at baseline and interval increases were normalized to time-to-follow-up. Primary outcome was annual rate of posterior LV wall thickening. One hundred one patients met inclusion criteria with a mean (SD) follow-up time of 1270 (693) days. Overall mean (SD) rate of LV wall thickness change was 0.534 (0.750) mm per year. Mean (SD) absolute LV wall thickness at most recent follow-up was 10.97 (2.85) mm for men, 9.69 (2.03) mm for women. Multivariate analysis demonstrated that higher rates of LV wall thickening were associated with narrower graft diameters (P = 0.0311). Greater absolute LV wall thickness at follow-up was associated with narrower grafts (P= 0.0155) and greater graft oversizing (P= 0.0376). Logistic regression demonstrated individuals who met criteria for LV hypertrophy were more likely to have narrower stent-grafts (P= 0.00798) and greater graft oversizing (P= 0.0315). LV wall thickening occurred to a greater degree in individuals with narrower stent-grafts and higher rates of graft oversizing. This has significant implications for long-term cardiovascular health in younger patients may undergo TEVAR for atypical indications. Particular attention should be paid to long-term effects of stent-graft oversizing when selecting grafts in such populations.

Effectiveness of personal protective equipment—Yes, the buck and virus can stop here

We conducted an observational study of a multi-center healthcare system to determine the effectiveness of our infection control/PPE program during the care of COVID-19 patients. The COVID-19 conversion rate in the patient care setting was 0.70%. Comparatively, the conversion rate noted in the non-patient care/community setting was 15.17%.

Abstract PS6-34: Real life impact of TAILORx trial in a multi-center healthcare system: A comparison of management practice one year before and after the release of the trial

Abstract Introduction: Oncotype DX is a 21 gene assay which has been shown to be useful in predicting the risk of breast cancer recurrence. TAILORx trial compared survival with the use of hormonal therapy (HT) vs. chemo-hormonal therapy (CHT) in early-stage, Hormone receptor-positive, HER2-negative, axillary lymphnode-negative breast cancer who had an Oncotype DX recurrence score in the intermediate range (11-25), The study found HT to be non-inferior to CHT in that group, especially in women older than 50. Materials and methods: We studied 1084 patients with hormone receptor-positive, HER-2 negative early stage breast cancer at a multi-center setting in South Dakota and North Dakota who were diagnosed one year before and after the results of the TAILORx trial were presented. We aimed to identify any change in practice after the trial was published as compared to the year prior. Chi-square analysis was used to compare demographics of patients and management practices before and after the TAILORx trial publication. Results: We did not find any statistically significant change in Oncotype DX testing frequency across various age groups, tumor sizes, tumor grades or amongst patients who had lymphnode negative or one axillary lymph node positive disease (Table-1).We also did not find any statistically significant difference in management of early stage breast cancer patients (Table-2) that matched our inclusion criteria and had an intermediate risk Oncotype Dx score of 11-25(n=266). Conclusion: Our results indicate that management of early stage breast cancer at our center was not significantly impacted by the results of TAILORx. Rare use of CHT prior to TAILORx reporting suggests that practice prior to this trial was largely based on earlier trials suggesting minimal benefit for CHT in the intermediate risk group. Larger studies may be able to identify smaller changes in practice resulting from this study and should be pursued. Table-1: Frequency of Oncotype Dx testing one year before and after the TAILORx trial was released overall and in various sub-categories based on age of the patient, tumor size and tumor grade. Last row indicates the frequency comparison in patients who had one axillary lymph node positive status.Before TAILORx (N=512)After TAILORx (N=572)p-valuen (%)n (%)Overall204 (40)234 (41)0.7212Age&amp;lt; 5044 (46)31 (37)0.225450 - 69121 (46)146 (49)0.4519Equal or &amp;gt; 7039 (26)57 (30)0.3986Tumor Size&amp;lt; 1 cm41 (25)50 (28)0.53881 - 1.9 cm97 (51)122 (53)0.60552 - 2.9 cm40 (44)44 (42)0.77283+ cm24 (39)18 (32)0.4161Tumor Grade156 (39)63 (42)0.62002113 (48)135 (47)0.8542334 (26)35 (27)0.9768LN Positive31 (33)36 (32)0.9403 Table-2: Comparison of treatment received by patients in the intermediate risk group (score:11-25) based on Oncotype Dx test before and after the release of TAILORx trial , Chi sq p-value=0.5635, HT (Hormonal Therapy), CT (Chemotherapy).Before TAILORxAfter TAILORxHT + CTn=15n=135.91%5.12%HT Alonen=108n=11842.52%46.46% Citation Format: Mahum Shahid, Moataz Ellithi, Mohamed Abdallah, Arsalan Arshad, Mansi Oberoi, Mckenna L Eisenbeisz, Christopher M VanHove, Ty A Moody, Isaak N Ailts, Andrew J Foley, Morgan Nelson, Jonathan Bleeker. Real life impact of TAILORx trial in a multi-center healthcare system: A comparison of management practice one year before and after the release of the trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS6-34.

Female Gender Is Associated with Increased Thrombus Burden within Stent Graft Following Thoracic Endovascular Aortic Repair

Mural thrombus within stent grafts develops at an unclear incidence following thoracic endovascular aortic repair (TEVAR). The significance of this phenomenon has not been determined, nor have the risk factors for development of intragraft thrombus. Small graft diameter is hypothesized to be a risk factor for thrombus development. A retrospective analysis was performed of a multicenter health-care system including all patients who underwent TEVAR between July 2011 and July 2019 with at least one year of subsequently available surveillance contrast-enhanced commuted tomography imaging. Standard demographic, preoperative, intraoperative, and postoperative variables were collected. Measurements were obtained via direct off-line images from computed tomography scans. Patent intragraft diameters were compared with baseline and interval change values were normalized to time to follow-up. The primary outcome measure was annual rate of intragraft thrombus formation. There were 208 patients who met the inclusion criteria (94 women, 114 men) with a median follow-up of 822 days. The mean (standard deviation) annual rate of percent intragraft diameter reduction was 10.5% (7.7%) for women and 7.6% (5.6%) for men (P = .0026). Multivariate analysis demonstrated female sex (P = .0283), preoperative diagnosis of hypertension (P = .0449), and need for coverage of the left subclavian artery (P = .0328) were all significant predictors of intragraft thrombus formation. Small aortic diameters were not independently found to be associated with development of thrombus, nor was concomitant use of antiplatelet or anticoagulation medications. High rates of thrombus formation, defined as >20% intragraft diameter reduction, were associated with increased need for any reintervention, including for malperfusion, endoleak, and symptomatic aneurysm (P = .0249). Kaplan-Meier estimate demonstrated a significant sex-associated difference in high rates of intragraft thrombus formation (P = .00189) (Fig). In this analysis, female sex is shown to be the most significant nonmodifiable risk factor for intragraft thrombus formation following TEVAR. Development of thrombus is not benign as such findings were associated with increased need for reintervention. This finding may be attribuTable to differences in aortic compliance or sex-associated differences in coagulation pathways and merits further investigation. Surveillance following thoracic stent grafting must account for patient-specific variations in complication risk.

Abstract 16816: Direct Oral Anticoagulants Compared to Warfarin for the Treatment of Left Ventricular Thrombus: A Multi-Center Experience

Introduction: Left ventricular thrombus (LVT) is associated with high risk of major adverse cardiovascular events (MACE) and mortality. Although warfarin is standard of care for LVT prevention and treatment, there is rising interest in the role of direct oral anticoagulants (DOACs). The goal of this study is to evaluate clinical outcomes of patients with LVT treated with DOACs compared to those treated with warfarin. Methods: Patients within a regional, multi-center health care system diagnosed with LVT from 2014-2018 were retrospectively identified through search of the electronic medical record. Demographic data, comorbidities, anticoagulation treatment, ejection fraction, and LVT etiology were recorded. Clinical outcomes including LV thrombus resolution, bleeding, and all-cause mortality were determined. Results: Demographic data is summarized in Table 1. Of 212 identified patients, 140 (66%) were treated with warfarin, 57 (26.9%) with DOAC, and 7 (3.3%) with low molecular weight heparin. Of these, 158 (74.5%) were on concomitant antiplatelet therapy. One patient was treated with antiplatelet therapy alone, and 7 patients received neither anticoagulation nor antiplatelet therapy. Patients treated with DOAC had no significant differences compared to those treated with VKA with respect to LVT resolution (69.3% vs 64.9, p = 0.95), hemorrhagic stroke (2.1% vs 1.8%, p = 0.86), ischemic stroke (2.1% vs 3.5%, p = 0.58), significant bleed (9.2% vs 12.3%, p = 0.78), and all-cause mortality (13.6% vs 15.8%, p = 0.17). Conclusions: In this large, multi-center retrospective study, clinical outcomes and adverse events of patients treated with DOAC for LVT are similar to VKA-treated patients. Given the observational nature of this study, randomized controlled studies are needed to validate these findings.

Pregnancy and Preeclampsia Are Associated With Acute Adverse Peripheral Arterial Events.

Acute peripheral arterial events, such as aortic dissection, carotid artery dissection, vertebral artery dissection, and ruptured renoviseral aneurysms, have been reported during pregnancy in case series, but there is a paucity of population-based data. This study sought to establish pregnancy and preeclampsia as risk factors for acute peripheral arterial events. Approach and Results: All women who gave birth between 1998 and 2020 within a multicenter health care system were identified. Births that occurred in women <18 or >50 years of age were excluded. Primary outcome was any acute peripheral arterial event that was symptomatic or required intervention. Cox regression model was used to evaluate the association between vascular events and pregnancy as a time-varying covariate. The pregnancy exposure period was from the estimated date of conception to 3 months postpartum. There were 277 697 pregnancies (81.3% deliveries, 17.0% abortions, and 1.7% ectopics) among 176 635 women with 1.68 million patient-years of total follow-up (median, 7.9 years; interquartile range, 2.4-16.2). Preeclampsia complicated 5.3% of pregnancies; 67 790 of 225 763 (30.0%) deliveries were delivered by cesarean. Ninety-six acute arterial events occurred during follow-up, of which 24 occurred during pregnancy, including the postpartum period. Pregnancy (hazard ratio, 1.85 [95% CI, 1.01-3.38]; P=0.046) and preeclampsia (hazard ratio, 10.9 [95% CI, 5.24-22.7]; P<0.001) were significant independent predictors of acute arterial events. While taking into account limitations from estimating conception and outcome dates, pregnancy, especially when complicated by preeclampsia, is associated with an increased risk of acute peripheral arterial events.

Heart Failure Hospitalization Trends During the Early Phase of the COVID 19 Pandemic

PurposeTo quantify the change in heart failure (HF) hospitalizations observed in the early phase of the COVID-19 pandemic across a large, multi-center health care system.MethodsMHealth Fairview encompasses four hospitals (one academic, three community-based) in the Minneapolis, Minnesota metro area. To compare HF hospitalization trends, two inpatient samples were created using HF discharges in the following time periods: pre COVID-19 (February 28, 2019-February 28, 2020) and post COVID-19 (April 1, 2020- May 15, 2020). March 2020 was excluded as this represented a transition point of the pandemic in the United States. Average number of discharges per day as well as demographics, diagnosis related group (DRG) codes, and inpatient mortality was then compared between the two inpatient HF samples.ResultsThe pre COVID-19 group had 2,601 patients with an average of 7.1 (+/-3) discharges per day. The post COVID-19 group had 210 patients with an average of 4.7 (+/-1.7) discharges per day, which represented a 34% reduction in HF discharges (p <0.001). No statistically significant differences were observed between the pre and post COVID-19 inpatient samples with respect to age (76 vs. 75 years, p = 0.25), gender (46% vs. 48% male, p = 0.7), and DRG codes (DRG 291: 78% vs. 85% p = 0.15). Inpatient HF mortality pre and post COVID-19 was not significantly different (3% vs. 2.9%, p = 0.99).ConclusionHF hospitalizations have decreased significantly during the early phase of the COVID-19 pandemic in this multi-center health care system, however the make-up of hospitalized patients remains similar. There is an urgent need to provide continued access to safe hospital care during the pandemic and to inform HF patients that inpatient care remains available.

Quantifying the decrease in emergency department imaging utilization during the COVID-19 pandemic at a multicenter healthcare system in Ohio.

PurposeTo illustrate the change in emergency department (ED) imaging utilization at a multicenter health system in the state of Ohio during the COVID-19 pandemic.MethodsA retrospective observational study was conducted assessing ED imaging volumes between March 1, 2020, and May 11, 2020, during the COVID-19 crisis. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization in the ED was compared with new COVID-19 cases in our region. Utilization was first categorized by modality and then by plain films and computed tomography (CT) scans grouped by body part. CT imaging of the chest was specifically investigated by assessing both CT chest only exams and CT chest, abdomen, and pelvis (C/A/P) exams. Ultimately, matching pair-wise statistical analysis of exam volumes was performed to assess significance of volume change.ResultsOur multicenter health system experienced a 46% drop in imaging utilization (p < 0.0001) during the pandemic. Matching pair-wise analysis showed a statistically significant volume decrease by each modality and body part. The exceptions were non-contrast chest CT, which increased (p = 0.0053), and non-trauma C/A/P CT, which did not show a statistically significant volume change (p = 0.0633).ConclusionED imaging utilization trends revealed through actual health system data will help inform evidence-based decisions for more accurate volume predictions and therefore institutional preparedness for current and future pandemics.

The Incidence of Venous Thromboembolism Following Pelvic and Lower Extremity Trauma Despite Adherence to Modern Prophylactic Protocols.

Describe the incidence of venous thromboembolism (VTE) in patients with pelvic and lower extremity long bone trauma in the setting of modern prophylaxis. Retrospective health-system database study. Multi-center health care system. Database query from 2010 to 2017 identified 11,313 adult trauma patients who received open reduction internal fixation of pelvic, acetabular, femoral neck, or intertrochanteric fractures, or received intramedullary nailing (IMN) of the femoral or tibial shaft. Patients with incomplete prophylaxis, prior history of VTE, coagulopathy, or concomitant lower extremity fracture were excluded. Mechanical and chemical VTE prophylaxis following pelvic or lower extremity fracture fixation. VTE rates. The overall VTE rate was 0.82% [0.39% deep venous thromboses (DVT); 0.43% pulmonary emboli (PE)]. By procedure, pelvic open reduction and internal fixation (ORIF) and femoral IMN had the highest VTE rates 1.70% (0.98% DVT; 0.78% PE) and 1.33% (0.75% DVT; 0.58% PE), whereas tibial IMN had the lowest incidence of VTE 0.34% (0.17% DVT; 0.17% PE). Among hip fractures, femoral neck ORIF had a VTE rate of 0.98% (0.59% DVT; 0.39% PE), whereas intertrochanteric ORIF had lower rates of 0.59% (0.20% DVT; 0.39% PE). Despite adherence to modern VTEp protocols, nonpreventable VTE occur in 0.82% of pelvic and lower extremity orthopaedic trauma patients. Incidence ranged between 0.34% and 1.70% depending on injury/fixation method with the highest rate observed in pelvis ORIF followed by femoral IMN. In the era of pay for quality performance, it is important for health systems and auditing agencies to reconcile the difference between preventable and nonpreventable VTEs. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Incidence of squamous cell carcinomas of the head and neck following prolonged pegylated liposomal doxorubicin

Despite numerous case reports, the incidence of a secondary diagnosis of head and neck squamous cell carcinoma (HNC) following pegylated liposomal doxorubicin (PLD) treatment is unknown. Computerized pharmacy records were searched at a large, multi-center healthcare system for patients who received PLD. Electronic medical records were searched to identify the patient's age at treatment initiation of PLD, diagnosis for which they were treated with PLD, number of courses and total cumulative dose of PLD (TCDPLD) and secondary malignancies. Published PLD associated HNC was utilized to determine the lowest and median TCDPLD doses associated with HNC. One thousand two hundred ninety eligible patients who had been treated with PLD were identified. The lowest TCDPLD associated HNC in the literature is 405 mg/m2. In our healthcare system, 275 patients received more than 400 mg/m2 yielding a risk of 0.004%. One hundred fifty-one patients received the lowest TCDPLD associated with HNC cancer in our series which was 640 mg/m2 yielding a risk of 0.007%. Four of 30 patients (13.3%) developed HNC who received the median TCDPLD associated with HNC in the literature of 1440 mg/m2. Five of 20 patients (25%) receiving 1650 mg/m2 developed HNC in our healthcare system. Prolonged therapy with PLD is associated with an increased risk of HNC. This risk appears to be related to the cumulative dose varying from 0.004 to 13.3% at the lowest and median TCDPLD of reported cases in the literature, respectively. Oncologists need to be aware of this risk and to screen patients appropriately.

Off-label dosing of non–vitamin K antagonist oral anticoagulants and clinical outcomes in Asian patients with atrial fibrillation

Off-label dosing non-vitamin K antagonist oral anticoagulants (NOACs) are commonly prescribed for Asian patients with atrial fibrillation (AF). The purpose of this study was to investigate the associations between inappropriate dosing of NOACs and clinical outcomes. We used medical data from a multicenter health care system in Taiwan, which included 2068, 5135, 2589, 1483, and 2342 AF patients taking dabigatran, rivaroxaban, apixaban, edoxaban, and warfarin, respectively. The risks of ischemic stroke/systemic embolism (IS/SE) and major bleeding in patients treated with underdosing or overdosing NOACs were compared to those of on-label dosing NOACs and warfarin. About 27% and 5% of AF patients were treated with underdosing and overdosing NOACs, respectively. Compared to on-label dosing, underdosing NOACs were associated with a significantly higher risk of IS/SE (adjusted hazard ratio [aHR] 1.59; 95% confidence interval [CI] 1.25-2.02; P <.001), whereas overdosing NOACs were associated with a significantly higher risk of major bleeding (aHR 2.01; 95% CI 1.13-3.56; P = .017). Compared to warfarin, the 4 on-label dosing NOACs were associated with a comparable risk of IS/SE and a significantly lower risk of major bleeding, whereas underdosing NOACs were associated with a higher risk of IS/SE (aHR 1.46; P = .012). About 3 in 10 Asian AF patients were treated with off-label dosing NOACs in daily practice. Compared to on-label dosing, underdosing was associated with a higher risk of IS/SE, whereas overdosing was associated with a higher risk of major bleeding. Thus, even for Asian AF patients at higher risk for bleeding, NOACs still should be prescribed at the dosing based on clinical trial criteria and guideline recommendations.

Traumatic Hip Fracture and Primary Elective Total Hip Patients are Not the Same: A Comparison of Comorbidity Burden, Hospital Course, Postoperative Complications, and Cost of Care Analysis.

To compare patient admission comorbidity profiles, length of stay, readmission rate, postoperative complications, mortality rate, and cost of care between acute geriatric hip fractures (HF) and elective total hip arthroplasties (THA). Retrospective cohort. Multicenter health care system. Eighteen thousand forty-two geriatric HF treated with operative fixation or arthroplasty and 8761 elective total hip patients were reviewed. Charlson Comorbidity Index, length of stay, ICU admission, readmission rate, postoperative complications, mortality rates, and cost of care. Medical comorbidities: chronic pulmonary disease, chronic kidney disease, coronary artery disease, heart failure, liver cirrhosis, and cerebrovascular disease were higher in HF patients as was mean Charlson Comorbidity Index (P < 0.001). Albumin was lower and HgbA1c higher in HF patients (P < 0.001). Average length of stay was 5.0 versus 2.6 days (P < 0.001) with 8.5% of HF patients being managed in the ICU versus 1.8% of THA patients. Readmission rates for HF and THA patients were 21.4% and 6.2%, respectively (P < 0.001). Minor and major complications were higher in the HF cohort (P < 0.001), as were 30-day (1.97% vs. 0.17%) and 1-year mortality rates (3.49% vs. 0.40%) (P < 0.001). Mean hospital cost of care was nearly 15,000 US dollars more expensive in HF patients when compared to the elective THA cohort (P < 0.001). HF patients have increased comorbidity burdens, lengths of stay, ICU admissions, readmission rates, complications, mortality, and costs of care than patients with elective total hip arthroplasty. In the era of pay for quality performance, health systems must reconcile the difference between these 2 patient cohorts. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

325. Cancer Screening Disparities among Persons Living with HIV (PLWH)

BackgroundCancer is now the leading cause of mortality for persons living with HIV (PLWH) in the United States, but it is uncertain whether PLWH access cancer screening that could lower this burden. We sought to assess cancer screening for breast, cervical, and colon cancer among PLWH compared with the HIV-uninfected population at a multicenter healthcare system over the past two decades.MethodsData were obtained from a prospective, observational HIV clinical care cohort comprised of PLWH engaged in care in the Partners Healthcare System. Patients eligible for cancer screening between the years 2002 and 2016 were included. Patients were matched in a maximum of 1:4 ratio with HIV-uninfected patients from the Massachusetts General Primary Care Practice-Based Research Network based on age, sex, race, year of study entry, and length of follow-up. The mean proportion of time in which eligible patients were guideline concordant for cervical, breast, and colon cancer screening was assessed. Non-parametric tests were used to compared screening rates between PLWH and HIV-infected and on the basis of multiple clinical and sociodemographic factors.ResultsDuring the observation period, a total of 495 PLWH were eligible for breast cancer screening, 1011 for cervical cancer screening, and 1965 for colon cancer screening. For each screening group, the majority of PLWH were on antiretroviral therapy (ART) and had relatively high CD4 cell counts (Table 1). Screening rates for PLWH compared with controls were 67.3% vs. 82.8% (P < 0.0001) for breast cancer, 49.0% vs. 73.3% (P < 0.0001) for cervical cancer, and 92.7% vs. 91.2% (P = 0.96) for colon cancer (Figure 1). Among PLWH, factors significantly associated with lower rates of screening guideline concordance were older age, lower CD4 count, HIV-1 RNA >1000 copies/mL, and HIV duration < 5 years for breast cancer, and older age, white race, English language, and lack of ART use for cervical cancer.ConclusionAmong patients engaged in longitudinal care, PLWH had significantly lower rates of screening for breast and cervical cancer than HIV-uninfected. Disparity is not explained by racial or primary language differences. Further work to improve access to cancer screening for PLWH is needed. Disclosures All authors: No reported disclosures.

719 Utilization Analysis of a Treat to Target Approach for Inflammatory Bowel Disease: A Multi-Center Health Care System Review

INTRODUCTION: A treat-to-target (TT) strategy, setting mucosal healing (MH) in inflammatory bowel diseases (IBD) as the desired treatment endpoint, is currently favored by experts. Advocates of this approach recommend the intensification of medical therapy to reach the goal of MH, even in patients who are in steroid free clinical remission. The utilization and practice of the TT strategy is unknown. METHODS: A retrospective chart review was performed for all IBD patients in the Northwell Health system to identify those in clinical remission who underwent colonoscopy between 01/01/2016 and 12/31/2018. Clinical remission at the time of colonoscopy was defined by a stable, steroid free IBD drug regimen and no IBD related surgery or hospitalization for 6 months prior. Patients in clinical remission but without MH reported on colonoscopy were defined as TT candidates. Demographic and treatment data were extracted from the medical record. We examined the frequency and type of TT utilization, defined as escalation of medical therapy within 1 month of the index colonoscopy. Analysis of variables associated with TT utilization was performed using the chi-square test. RESULTS: 960 patients had a colonoscopy by 34 different gastroenterologists during the study period. 382 patients met criteria for clinical remission, 248 of whom had gross disease activity classifying them as TT candidates, Table 1. None of the 134 patients with MH had a change in their medication regimen within 1 month of colonoscopy. Among TT candidates 42 (16.93%) had utilization of TT during the 1 month follow-up. Patients utilizing TT were more likely to have no baseline medication use, 39.5% vs. 20.87 (P = 0.0102). There was decreased utilization of TT among those patients already using immunologic and/or biologic therapies, 21.42% vs. 38.88% (P = 0.03), Table 2. Patients utilizing vs. not utilizing TT where similar by age, gender, IBD type, and CD surgical history. For patients utilizing TT, strategies included initiation or modification of biologic therapy more commonly among CD vs. UC/indeterminate colitis patients, 64.29% vs. 10.71% (P = 0.0005). TT utilizing 5-ASA was more common for UC/indeterminate colitis vs. CD, 82.14% vs. 35.71% (P = 0.003), Table 3. CONCLUSION: We have demonstrated a low rate of TT utilization in our study population. When used, a TT strategy favoring biologic therapy was more common in CD. Further validation of TT, along with physician and patient education, will likely be needed if TT is to become widely adopted.

Reduction in coronary artery bypass grafting surgery mortality and morbidity during a 3-year multicenter quality improvement project

ObjectiveRisk-adjusted operative mortality is a key quality measure for isolated coronary artery bypass grafting. Through a multicenter quality improvement initiative, we sought to improve this measure at 14 surgical programs within a large and geographically dispersed health care system. MethodsObserved mortality and combined mortality/morbidity rates for isolated coronary artery bypass grafting were collected from January 2014 to June 2017. Expected mortality and mortality/morbidity rates were determined using the Society of Thoracic Surgeons risk models. The observed/expected ratios during the baseline (2014) and final 12-month outcome period were compared. The quality improvement intervention was multifaceted and surgeon led, and consisted of (1) regular sharing of unblinded data, (2) standardized quality improvement processes, (3) regular system-wide quality improvement meetings, (4) annual observed/expected mortality targets, (5) identification of underperforming institutions and creation of nonpunitive quality improvement action plans, and (6) implementation of checklists to drive perioperative care standardization. ResultsThe observed/expected ratio of mortality was 1.19 during the baseline period and decreased to 0.59 for the outcome period (P = .004) without a change in expected mortality or case volume. The observed/expected ratio decreased for mortality/morbidity, and mortality without antecedent morbidity was almost eliminated. ConclusionsA significant and clinically meaningful 50% reduction in the observed/expected ratio for isolated coronary artery bypass grafting mortality was observed during a multifaceted quality improvement initiative across a large multicenter health care system. Morbidity also decreased. Keys to success included surgeon leadership and engagement, frequent unblinded data sharing, development of standardized quality improvement processes, improvement and standardization of care delivery, setting of quality improvement targets, and a shared vision for improved patient outcomes.

1801. Impact of Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) on Clinical Outcomes in Patients with Gram Positive Blood Cultures in a Diverse, Multicenter Healthcare System With a Central Laboratory

BackgroundRapid diagnostic testing in combination with real-time antimicrobial stewardship intervention can reduce time to de-escalation of empiric antibiotics and discontinuation of unnecessary therapy. This study aims to evaluate the clinical impact of Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) for Gram-positive organism identification for blood cultures across a healthcare system comprised of pediatric, adult academic, and adult community hospitals utilizing a central microbiology laboratory with unique antimicrobial stewardship resources at each site.MethodsThis multicenter retrospective study compared patients with a positive blood culture for a Gram-positive organism identified via MALDI-TOF MS to a historical cohort identified using conventional methods. Primary outcome was time to optimal therapy (TTOT). Secondary outcomes included time to effective therapy, duration of therapy, time to microbiologic clearance, hospital length of stay (LOS), ICU LOS, recurrence, readmission, in-hospital mortality, and all-cause mortality.ResultsThis study included 129 cultures (12% pediatric patients) in the conventional period and 129 cultures (19% pediatric patients) in the MALDI-TOF MS group. Of the total 258 blood cultures included, 147 (57%) represented true bloodstream infection and 111 (43%) were deemed to be contaminants. Despite a median reduction in time to organism identification (60.0 vs. 45.4 hours, P < 0.001), there was no difference in the primary outcome of overall median TTOT between the two groups (70.7 hours vs. 65.9 hours, P = 0.407). There were no significant differences for any secondary outcomes. Overall TTOT was longer as distance from the central laboratory increased (47.3 hours at central site vs. 76.9 hours at distance >30 miles). Among contaminants, median TTOT was reduced from 72.5 hours with conventional methods to 59.8 hours with MALDI-TOF MS (P = 0.015). Conclusion. Implementation of MALDI-TOF MS for organism identification may not reduce time to optimal therapy in patients with true Gram-positive bacteremia. However, it can result in a significant reduction in time to discontinuation of unnecessary therapy for patients with contaminated cultures. Figure 1. Differences in outcomes for conventional methods vs. MALDI-TOF MS Disclosures All authors: No reported disclosures.

Surveillance Recommendations after Thoracic Endovascular Aortic Repair Should Be Based on Initial Indication for Repair

Current surveillance recommendations after thoracic endovascular aortic repair (TEVAR) include contrast-enhanced computed tomography (CT) scans at 1-, 2-, 6-, and 12-month intervals, with annual scans thereafter. Patient compliance with such schedules remains inconsistent for all etiologies of aortic disease. It remains unclear which boundaries prevent compliance and whether compliance is associated with improved aorta-specific outcomes. A retrospective analysis was performed of a multicenter health-care system's electronic medical records to include all patients who underwent TEVAR from July 1, 2011 to April 1, 2016. Patients were assigned a compliance score of 0 through 4 based on the number of images received at the recommended time intervals. Whether patients underwent any postoperative imaging within 1 year of discharge was also recorded. Patients who died within 12months of discharge were excluded. Aorta-specific complications included postoperative sac expansion, rupture, or need for additional aortic intervention. A total of 262 patients were included; of whom, 203 (77.5%) received at least one postoperative contrast-enhanced CT scan. Race, insurance status, and distance to hospital were not associated with 12-month compliance or compliance score (all P>0.05). Regarding 12-month compliance, 76.2% of aneurysm patients, 81.6% of dissection patients, 72.2% of transection patients, and 72.2% of penetrating aortic ulcer patients underwent at least 1 CT scan within the first year (all P>0.05). There were no differences in compliance score based on indication for repair. The overall aorta-related complication rate was 34.7%. TEVAR for dissection was associated with increased long-term aorta-specific complications (49.5%, P<0.05 when compared with other indications). In this large, multihospital analysis of TEVAR outcomes, there was no difference in compliance among patients undergoing TEVAR for major indications, but patients with dissection who required TEVAR had a significant difference in aorta-specific complication rates. TEVAR for dissection should be subject to stricter surveillance guidelines than TEVAR for other indications.

Interinstitutional variation in predictive value of the ThyroSeq v2 genomic classifier for cytologically indeterminate thyroid nodules

BackgroundThe ThyroSeq v2 next-generation sequencing assay estimates the probability of malignancy in indeterminate thyroid nodules. Its diagnostic accuracy in different practice settings and patient populations is not well understood. MethodsWe analyzed 273 Bethesda III/IV indeterminate thyroid nodules evaluated with ThyroSeq at 4 institutions: 2 comprehensive cancer centers (n = 98 and 102), a multicenter health care system (n = 60), and an academic medical center (n = 13). The positive and negative predictive values of ThyroSeq and distribution of final pathologic diagnoses were analyzed and compared with values predicted by Bayes theorem. ResultsAcross 4 institutions, the positive predictive value was 35% (22%–43%) and negative predictive value was 93% (88%–100%). Predictive values correlated closely with Bayes theorem estimates (r2 = 0.84), although positive predictive values were lower than expected. RAS mutations were the most common molecular alteration. Among 84 RAS-mutated nodules, malignancy risk was variable (25%, range 10%–37%) and distribution of benign diagnoses differed across institutions (adenoma/hyperplasia 12%–85%, noninvasive follicular thyroid neoplasm with papillary-like nuclear features 5%–46%). ConclusionIn a multi-institutional analysis, ThyroSeq positive predictive values were variable and lower than expected. This is attributable to differences in the prevalence of malignancy and variability in pathologist interpretations of noninvasive tumors. It is important that clinicians understand ThyroSeq performance in their practice setting when evaluating these results.