Number Of Inpatient Hospital Days Research Articles

Racial Differences in Inpatient Hospital Services Utilization and Expenditure between American Indian and Alaska Native and non‐Hispanic White Older Adults with Dementia

AbstractBackgroundWhile American Indian and Alaska Native (AI/AN) and non‐Hispanic white (White) adults are at high risks for dementia, little is known about hospital utilization and expenditures among AI/ANs and Whites with dementia. The goal of this study is to examine characteristics associated with inpatient hospital services utilization and expenditures among AI/AN and White older adults with dementia, to understand what factors contribute to differences in utilization and expenditures between the two populations.MethodWe analyzed data on demographic characteristics, health coverage, chronic disease status, hospital utilization and expenditures from the CMS 2019 Medicare Master Beneficiary Summary File for all AI/AN (n = 16,324) and a 5% random sample of White (n = 139,335) adults aged ≥65 who had dementia in 2019. To examine associations between patient characteristics with utilization and expenditures, we employed Poisson and negative binomial models for utilization measures (1+ hospitalizations and number of inpatient hospital days) and a two‐part model (a gamma distribution with a log‐link function) for expenditures, while stratifying by race.ResultAI/AN adults were younger than White adults; a larger percentage were dually enrolled in Medicaid, had diabetes and ESRD, and lived in a rural county (p<0.01). Medicaid coverage is associated with higher inpatient hospital days and expenditures among AI/ANs (Incidence Rate Ratio (IRR) = 1.079; Marginal Effect (ME) = $3,313, p<0.01) but is associated with lower days and expenditures among Whites (IRR = 0.874; ME = ‐$1,438, p<0.01). The association between living in a rural county with expenditures followed a pattern similar to that of Medicaid coverage. Unadjusted mean hospital days and expenditures were 4.84 and $27,559 (AI/ANs) and 3.86 and $23,009 (Whites), respectively. When data for AI/ANs and Whites were combined, the average marginal expenditure for AI/ANs, compared to Whites was $4,550 in unadjusted model, but reduced to $2,772 when we adjusted for age, gender, comorbidities, and social determinants of health.ConclusionUnderstanding and addressing characteristics associated with racial differences in hospital use and expenditures among dementia patients may be helpful for health care resource planning and efficient use. In‐depth research is required to understand the contrasting differences in the impact of Medicaid on expenditures between AI/AN and White adults with dementia.

Association of frailty with health service use among older Chinese adults: analysis of population-based panel data.

Frailty is a common syndrome characterized by rapid growth in the aging population that has an impact on healthcare systems. This study aimed to investigate the impact of frailty on health service use and whether this effect varies with chronic diseases and socioeconomic status among older individuals in China. A balanced panel data analysis was conducted on 3,306 older individuals who completed follow-ups for the three waves of the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, and 2015. The Physical Frailty Phenotype (PFP) Scale was used to assess frailty status. Negative binomial regression was used to test the associations between frailty status, outpatient visits in the past 4 weeks, and annual inpatient hospital days. Compared with robust individuals, individuals with pre-frail or frail status were likely to report a higher number of outpatient visits [pre-frail: incidence rate ratio (IRR) = 1.28, 95% CI = 1.16-1.41; frail: IRR = 1.45, 95% CI = 1.23-1.71], and inpatient hospital days (pre-frail: IRR = 1.40, 95% CI = 1.24-1.58; frail: IRR = 2.17, 95% CI = 1.81-2.60) after controlling for all covariates. All five frailty components (weight loss, exhaustion, low physical activity, slowness, and weakness) were associated with a higher number of inpatient hospital days, and two components (weight loss and exhaustion) were associated with a higher number of outpatient visits. The effect of frailty on inpatient hospital stays persisted in different socioeconomic groups, across all health insurance programmes and physical comorbidities. Frailty is associated with greater health service use among older individuals. Effective screening, prevention, intervention, and management of frailty may be important to reduce health service use.

Patient Pathway Comparison for Total Hip Replacement in the United States and Germany — Why the Payment Model Matters

Summary As developed countries are faced with both the challenge of rising health care costs and the quest for improved medical outcomes, cross-global learnings can illuminate advances in medical best practices as well as the incentive system that leads to reduced costs and improved patient outcomes. Using the example of elective primary total hip replacements (THRs) for osteoarthritis — one of the most common elective surgical procedures in Organisation for Economic Co-operation and Development countries — the authors illustrate differences in clinical and financial practices between a capitation-based payment model used by Kaiser Permanente, a private, integrated health system in the United States, and a fee-for-service model used by the AOK Federation, a not-for-profit health insurance system that comprises 11 public health insurance plans with about 27 million insurees that is representative of Germany’s public health care system. The authors also shed some light on the different incentive structures and how they contribute to Kaiser Permanente achieving significantly better medical outcomes while using notably fewer resources than its counterparts in Germany. Applying Kaiser Permanente’s clinical practices for its patients with THRs, Germany would be able to increase quality of care and reduce the number of inpatient hospital days by more than 1.5 million as well as the number of postacute care inpatient days by 3.5 million per annum.

Efficacy and Safety of a Novel Non-Myeloablative Conditioning Regimen for Hematopoietic Cell Transplantation in Adults with Severe Aplastic Anemia

Introduction The distinct "age effect" that exists in severe aplastic anemia (SAA) following hematopoietic cell transplantation (HCT) favors the use of reduced intensity conditioning regimens in patients >40 years. For older adults, overall survival and disease-free survival (DFS) is reduced with increasing age and unrelated donor transplant are associated with higher rates of graft failure, Epstein-Barr virus (EBV) reactivation, and post-transplant lymphoproliferative disorders (PTLD) (Rice C, et al. BBMT 2019.). To overcome this, a novel, non-myeloablative conditioning regimen called FCR, which consists of fludarabine, cyclophosphamide, and rituximab, was designed at Vanderbilt University Medical Center (VUMC) and the associated VA Tennessee Valley Healthcare System (TVHS) for use in all SAA patients. This regimen was subsequently evaluated in the first 11 SAA patients treated at VUMC/TVHS and found to result in lower toxicity, graft-versus-host disease (GVHD), and viral reactivation with no graft failure or relapse compared to historical controls (Gatwood KS, et al. BMT 2018.). Given these initial favorable results, FCR has now been expanded as the preferred conditioning regimen for all SAA patients undergoing HCT at our center, warranting follow-up evaluation in a larger cohort. Methods Utilizing institutional registries, all SAA patients were identified who underwent first allogeneic HCT using an FCR regimen (Figure 1) between January 2016 and May 2022. VUMC and TVHS Institutional Review Boards approved this retrospective analysis. Outcomes analyzed included time to engraftment, incidence of graft failure, incidence of acute GVHD (aGVHD) and chronic GVHD (cGVHD), rate of viral reactivation, post-HCT disease status, and number of inpatient hospital days through day +100. An analysis of 1-year GVHD-free, relapse-free survival (GRFS) was conducted in evaluable patients, with differences between the curves determined using log-rank tests. Results Twenty-four SAA patients underwent HCT from January 26, 2016 to May 11, 2022, the majority of which were male with a median age of 43.5 years (range: 22-62). All patients received at least one line of therapy prior to HCT with the most common treatment being the combination of cyclosporin A with anti-thymocyte globulin with or without eltrombopag and/or corticosteroid. Median time from diagnosis to transplantation was 434.5 days (range: 84-6408). Patients received transplants from matched related (n=8), haploidentical (n=2), and matched unrelated donors (n=14) using either a peripheral blood (PB) or bone marrow (BM) stem cell source (PB=15, BM=9). Median time to neutrophil and platelet engraftment was 14 days (range: 10-25) and 18 days (range: 10-38), respectively. No patients experienced graft failure. At median follow-up of 806.5 days (range: 72-2180) post-transplant, all patients were alive and in remission. No patients developed grade III-IV aGVHD and no differences in grade I-II aGVHD rates were noted based on stem cell source. By date of last follow-up, mild to moderate cGVHD graded per 2014 NIH criteria developed in 7 and 3 patients, respectively. There were no cases of severe cGVHD. Only 2 patients experienced a viral reactivation (cytomegalovirus [CMV]=1, EBV=1) by date of last follow-up. The case of EBV reactivation did not require treatment and did not progress to PTLD. The median number of inpatient hospital days required post-engraftment through the first 100 days post-transplant was 5 days (range: 0-21). The unadjusted Kaplan-Meier estimate of 1-year GRFS was 86.3% (95% CI: 72.8%-100%) (Figure 2), with moderate cGVHD accounting for all GFRS events in the study cohort. Conclusions The use of our novel non-myeloablative conditioning regimen in SAA is well tolerated with 0% non-relapse mortality and 100% DFS with low GVHD rates at 1-year post-transplant. Despite a high-risk population with median age >40 years, using primarily matched unrelated donors, and majority peripheral blood stem cell source, there were no deaths and rates of complications remained low. This study further supports the findings of our previous study, redemonstrating low rates of toxicity, severe GVHD and viral reactivation with no graft failure, relapse, or mortality. The use of these regimens needs to be validated in a larger cohort as they have the potential to provide a new standard of care for pre-HCT conditioning in SAA patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Outcomes of a Novel Rituximab-Based Non-Ablative Conditioning Regimen for Hematopoietic Cell Transplantation in Severe Aplastic Anemia

IntroductionOlder patients with severe aplastic anemia (SAA) needing hematopoietic cell transplantation (HCT) typically require utilization of reduced intensity conditioning (RIC) regimens; however, use of RIC regimens in this population is limited by graft failure and transplant-related mortality due to toxicity and infections, particularly reactivation of Epstein-Barr virus (EBV). Novel RIC regimens with improved efficacy and decreased toxicity and risk of infectious complications are urgently needed to improve post-HCT outcomes for SAA patients.Patients and MethodsUtilizing institutional registries, we identified all SAA patients who underwent first allogeneic HCT using an FCR regimen (Figures 1A and 1B) between August 2014 and May 2017 at our institution for inclusion in this analysis. Post-transplant immune suppression comprised of tacrolimus and either methotrexate or mycophenolate mofetil. The Institutional Review Board approved this analysis and a waiver of informed consent was obtained. Medical records of all patients were reviewed by participating investigators. Assessment of graft-versus-host disease (GVHD) was performed following standard grading practice. An analysis of 1-year GVHD-free, relapse-free survival (GRFS) was conducted and compared to an historical cohort of all SAA patients transplanted with a non-FCR regimen at our institution since January 1999 (n=27), with differences between the curves determined using log-rank tests.Results11 SAA patients underwent HCT from August 1, 2014 to May 5, 2017, the majority of which were male with a median age of 41 years (range: 19-64). Most patients received one line of treatment prior to HCT (CSA+ATG=6, CSA=1, steroids=1) and received an HCT within a median of 205 days after diagnosis (range: 70-2090). All patients received transplants from matched or haploidentical donors (matched related=4, matched unrelated=5, haploidentical=2) using a peripheral blood stem cell source, except 1 patient who received a bone marrow graft. At median follow-up of 302 (range: 49-911) days post-transplant, all patients were alive and in remission with 100% donor peripheral blood chimerism with bone marrow biopsies documenting normal trilineage hematopoiesis. Average time to neutrophil and platelet engraftment was 15.4 days and 16 days, respectively. The median number of inpatient hospital days required in the first 100 days post-transplant was 11 days (range: 3-29). By day 100 post-transplant, 54.5% of patients developed some degree of acute GVHD (grade I=1, grade II=3, grade III=2). However, by date of last follow-up, all evaluable patients (10/11) had not developed chronic GVHD. Only 2 patients experienced a viral reactivation (1=cytomegalovirus (CMV), 1=CMV+EBV) by date of last follow-up post-transplant. The case of EBV reactivation did not require treatment and no patients developed post-transplant lymphoproliferative disorder. The unadjusted Kaplan-Meier estimate of 1-year GRFS was 81.8% (95% CI: 59.1-104.7%) in the study group versus 61.5% (95% CI: 42.9-80.1%) in the historical group (P=0.256) (Figure 1C) with death accounting for the greatest proportion of GRFS events in the historical population and grade III acute GVHD accounting for the two GRFS events in the study cohort.ConclusionsThe positive results from this study demonstrating low toxicity, GVHD, and EBV reactivation rates with no graft failure or relapse potentially justify the use of these novel outpatient non-myeloablative conditioning regimens in SAA patients of any age receiving transplantation from any donor source. Further prospective investigation in a larger population is warranted. [Display omitted] DisclosuresGatwood:Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Byrne:Pfizer: Membership on an entity's Board of Directors or advisory committees; Concert Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Karyopharm: Research Funding. Jagasia:Therakos: Consultancy, Research Funding; Mallinckrodt: Consultancy; Janssen: Consultancy, Research Funding. Savani:Jazz Pharmaceuticals: Speakers Bureau.

Reducing hospitalizations: Implementation of CADD pumps in infusion clinic at a Los Angeles safety net hospital.

e18648 Background: Computerized ambulatory drug delivery (CADD) pumps introduced in the 1980s made it possible to move infusion delivery from the hospital to the home. At Harbor-UCLA Medical Center, hundreds of scheduled chemotherapy admissions occur annually. The procurement and implementation of CADD pumps was a collaborative effort with members of pharmacy, nursing, physicians and administration. The implementation of CADD pumps for home chemotherapy demonstrated a cost-savings by decreasing the number of inpatient hospital days required for scheduled chemotherapy admissions. Methods: The first outpatient chemotherapy infusion by CADD pump began on 12/5/2017. Records from 12/5/2017 through 12/4/2018 (365 days) were reviewed to assess the benefit of CADD pumps, defined by inpatient hospital days avoided. Eight chemotherapy regimens were administered through outpatient CADD pumps; the equivalent number of inpatient hospital days were estimated based on inpatient hospital records between 2015 and 2017. The average number of hospital days that would have occurred inpatient per chemotherapy regimen was multiplied by the number of outpatient CADD pump chemotherapy infusions to estimate the number of inpatient hospital days avoided. Based on information provided by our hospital’s finance department, including reimbursement for inpatient and similar outpatient care, each hospital day avoided was estimated to provide $1,695 in cost-savings. On average, a typical hospitalization for infusional 5-FU chemotherapy was three days in length. Results: Over one year, 35 patients received a total of 178 outpatient CADD infusions. The average number of CADD infusions per patient was five. We estimated that 642 hospital bed days were saved over a 1-year period following the implementation of outpatient CADD pumps. With the estimate that each hospital bed day saved was valued at $1,695, we concluded a savings of $1.1 million dollars at our hospital through the implementation of CADD pumps within the first year. Conclusions: The implementation of CADD pumps for home chemotherapy demonstrated cost-savings by decreasing the number of inpatient hospital days required for scheduled chemotherapy admissions. This shift provides a superior value for the patient with equivalent treatment outpatient, spending less time in the healthcare setting, and reduced health care costs. [Table: see text]

An Interprofessional Collaborative Practice Can Reduce Heart Failure Hospital Readmissions and Costs in an Underserved Population

BackgroundHeart failure is a leading cause of hospitalization among adults in the United States. Nurse-led interprofessional clinics have been shown to improve heart failure outcomes in patients with heart failure, specifically decreasing readmission rates. Yet, there is little information on the impact of nurse-led interprofessional collaborative practice within an underserved population with heart failure. Thus, the purpose of this study was to compare the differences in readmission days and cost in patients followed by an interprofessional collaborative practice clinic (both engaged and not engaged) and those who did not establish care with the clinic. Methods and ResultsDemographic, clinical, and readmission data were compared among patients with heart failure (59% African American; 72% male; mean age, 49 years) stratified into 3 groups: engaged patients (n = 170), not-engaged patients (n = 103), and not-established patients (n = 111) who had an initial appointment to clinic but did not establish care. Patients with 6 months of data before and after the scheduled clinic visit were included in the study. Differences in baseline characteristics, frequency and length of hospital admissions, and costs were analyzed using analysis of variance, Wilcoxon matched-pairs testing, multivariate analysis of variance, logistic regression, and financial analytics. Overall, the number of inpatient hospital days decreased in the engaged group compared with those in the not-engaged and not-established groups (P < .001). The total cost savings were significantly greater in the engaged group ($1,987,379) (P < .001). ConclusionsThe findings of this study may steer health care providers to incorporate interprofessional collaborative practice into heart failure management with a particular focus on underserved populations.

Implementation, efficacy, costs and processes of inpatient equivalent home-treatment in German mental health care (AKtiV): protocol of a mixed-method, participatory, quasi-experimental trial

BackgroundOver the last decades, many high-income countries have successfully implemented assertive outreach mental health services for acute care. Despite evidence that these services entail several benefits for service users, Germany has lagged behind and has been slow in implementing outreach services. In 2018, a new law enabled national mental health care providers to implement team-based crisis intervention services on a regular basis, allowing for different forms of Inpatient Equivalent Home Treatment (IEHT). IEHT is similar to the internationally known Home Treatment or Crisis Resolution Teams. It provides acute psychiatric treatment at the user’s home, similar to inpatient hospital treatment in terms of content, flexibility, and complexity.Methods/designThe presented naturalistic, quasi-experimental cohort study will evaluate IEHT in ten hospitals running IEHT services in different German regions. Within a multi-method research approach, it will evaluate stakeholders’ experiences of care, service use, efficacy, costs, treatment processes and implementation processes of IEHT from different perspectives. Quantitative surveys will be used to recruit 360 service users. Subsequently, 180 service users receiving IEHT will be compared with 180 matched statistical ‘twins’ receiving standard inpatient treatment. Assessments will take place at baseline as well as after 6 and 12 months. The primary outcome is the hospital re-admission rate within 12 months. Secondary outcomes include the combined readmission rate, total number of inpatient hospital days, treatment discontinuation rate, quality of life, psycho-social functioning, job integration, recovery, satisfaction with care, shared decision-making, and treatment costs. Additionally, the study will assess the burden of care and satisfaction with care among relatives or informal caregivers. A collaborative research team made up of researchers with and without lived experience of mental distress will conduct qualitative investigations with service users, caregivers and IEHT staff teams to explore critical ingredients and interactions between implementation processes, treatment processes, and outcomes from a stakeholder perspective.DiscussionBy integrating outcome, process and implementation research as well as different stakeholder perspectives and experiences in one study, this trial captures the various facets of IEHT as a special form of home treatment. Therefore, it allows for an adequate, comprehensive evaluation on different levels of this complex intervention.Trial registrationTrial registrations: 1) German Clinical Trials Register (DRKS), DRKS000224769. Registered December 3rd 2020, https://www.drks.de/drks_web/setLocale_EN.do; 2) ClinicalTrials.gov, Identifier: NCT0474550. Registered February 9th 2021.

Examining Associations Between Legal Frameworks for Medical Planning and Intensity of End-of-Life Care

This study aims to understand the correlation between the legal framework around planning for medical treatment and the intensity of care received at the end of life. Advance directives (AD) allow an individual to legally document their wishes for medical treatment and end-of-life care, and durable powers of attorney (DPOA) allow them to identify an individual to make medical decisions on their behalf in the event they are no longer able. These laws vary greatly across time, place, and in their complexity. We estimated fixed effects model, which controls for time-invariant and state-specific factors affecting end-of-life care. Our primary outcome variable is the number of inpatient hospital days during the last six months of life, sourced from the Dartmouth Atlas Project. Our explanatory variables are hand-collected state-level legal statutes including whether the state (a) has default surrogate laws, (b) recognizes the ability to create a DPOA and/or AD, (c) permits oral directives, (d) authorizes a combined AD/DPOA, and (e) provides an official registry for ADs. Preliminary findings show recognizing DPOA and AD are negatively correlated with our outcome variable (-2.6 days; Std err 0.272) as are having default surrogate laws (-0.36 days; std err 0.157). However, allowing oral directives had an opposite effect (-.46 days; std err 0.157). Neither authorized combined AD/DPOAs nor AD registries resulted with significant correlations. These findings indicate that the existence of a basic framework such as default surrogate laws and a law governing ADs are key policy features correlated with reduced intensity in end-of-life care.

Outpatient BEAM Using Daily Etoposide and Cytarabine with Autologous Hematopoietic Stem Cell Transplantation for Lymphoma Is Feasible and Decreases Inpatient Length of Stay

Introduction: High dose therapy with carmustine, etoposide, cytarabine, and melphalan (BEAM) followed by autologous hematopoietic stem cell transplantation (AHCT) is the most common consolidation therapy for chemosensitive patients with relapsed/refractory Non-Hodgkin Lymphoma (NHL) and Hodgkin Lymphoma (HL) in the US. Inpatient hospitalization is usually required due to the twice daily dosing of etoposide and cytarabine, and patients remain admitted until neutrophil recovery. Utilizing our outpatient transplant program, we aimed to evaluate the feasibility and safety of outpatient BEAM with AHCT using daily dosed etoposide and cytarabine to enhance the patient experience and improve inpatient resource utilization. Methods: We performed a retrospective evaluation of patients treated in the outpatient setting at Memorial Sloan Kettering Cancer Center. Patients were eligible for outpatient AHCT if they did not have a clinical indication for inpatient continuous monitoring. Patients received BEAM conditioning consisting of carmustine on day -6 (300mg/m2), etoposide daily from day -5 through day -2 (200mg/m2/dose), cytarabine daily from day -5 through day -2 (400mg/m2/dose), and melphalan on day -1 (140mg/m2). AHCT on day 0, pegfilgrastim on Day +1, and supportive care were performed as per standard of care and institutional guidelines. Patients were seen daily by an advanced practice provider and HCT attending. Notably, service guidelines were revised to include a delayed emesis prophylactic regimen of oral dexamethasone (2mg bid) and lorazepam (0.5mg TID) from D+1 through D+7, which was initiated after the first three patients were treated. Patients were transfused packed red blood cells (pRBC) for hemoglobin &lt;7g/dl and platelets for &lt;20K/mcl. Results: From October 2018 to July of 2019, 13 patients (Hodgkin's lymphoma (n=5), mantle cell lymphoma (n=4), diffuse large B-cell lymphoma (n=2), T-cell lymphoma (n=2), and grey zone lymphoma (n=1)) were treated. The median age was 40 years (range 26-71), and the majority were male (69%). Median cell dose infused was 5.89 CD34+ cells/kg (range 2.53-10.66). Two patients received cell infusions over 2 days, and three patients received washed cell infusion products. Two patients completed transplant entirely outpatient; the remainder required hospitalization during their transplant course. Reasons for admission included neutropenic fever (n=4), nausea (n=2), tachycardia (n=2), hypoxia (n=1), and other (n=2). Patients were admitted on a median of Day +6 (range Day+1 - Day+11) and remained inpatient for a median of 4 days (range 3-14). Eight patients (62%) returned to the outpatient stem cell transplant clinic for management prior to day 30. One patient was re-hospitalized prior to day 30. The median number of hospital days saved was 13 days/per patient. In total, 170 hospital days were saved with this regimen. Engraftment and toxicities were similar to inpatient administration. Neutrophil engraftment occurred at a median of Day+9 (range 8-11) with a median of 6 days of ANC&lt;500 (IQR 8-11). Platelets comprised most of the transfusion support required, with a median of 4 platelet (range 2-8) and 2 pRBC (range 0-2) transfusions per patient. Grade 2 or higher diarrhea occurred for a median of 3.5 days (range 3-11) with 38% not having any diarrhea. A small percentage of patients required additional antiemetics outside the standard of care (23%). The median weight lost per patient was 2.5kg (range 0 - 10.3kg). Patients received intravenous fluid support with a median of 5 normal saline boluses (range 1-10). All patients maintained normal serum creatinine peri-transplant, with a median maximum serum creatinine of 0.9mg/dl (range 0.7-1.1). Six patients (46%) had engraftment syndrome. All patients were alive with a median follow-up of 91 days (range: 29-205). Conclusion: We found that BEAM followed by AHCT using daily dosed etoposide and cytarabine is feasible and safe for the outpatient setting with tolerability matching that of the traditional inpatient BEAM regimen. Moreover, this treatment method has the potential to reduce a considerable number of inpatient hospital days, while still safely maintaining a threshold for toxicity requiring inpatient admission. Disclosures Bhatt: Incyte: Consultancy. Landau:Pfizer: Membership on an entity's Board of Directors or advisory committees; Caelum: Membership on an entity's Board of Directors or advisory committees; Prothena: Membership on an entity's Board of Directors or advisory committees; Amgen: Research Funding; Takeda: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Karyopharm: Consultancy, Honoraria. Scordo:Angiocrine Bioscience, Inc.: Consultancy; McKinsey &amp; Company: Consultancy. Sauter:Juno Therapeutics: Consultancy, Research Funding; Kite/Gilead: Consultancy; Precision Biosciences: Consultancy; Genmab: Consultancy; Spectrum Pharmaceuticals: Consultancy; GSK: Consultancy; Celgene: Consultancy; Novartis: Consultancy; Sanofi-Genzyme: Consultancy, Research Funding. Giralt:Celgene: Consultancy, Research Funding; Takeda: Consultancy; Sanofi: Consultancy, Research Funding; Amgen: Consultancy, Research Funding. Shah:Amgen: Research Funding; Janssen: Research Funding.

Health Care Utilization in Transplanted Versus Non-Transplanted Sickle Cell Disease Patients

Sickle cell disease (SCD) is an inherited red blood cell disorder that leads to substantial morbidity and a heavy burden on the health care system. Nonmyeloablative allogeneic hematopoietic stem cell transplantation (HSCT) regimens using HLA-matched related donors have recently demonstrated high rates of engraftment and a favorable safety profile in adults with SCD. The long term effects of these HSCT regimens on health care utilization, particularly in SCD adults who have had a high burden of SCD-related acute and chronic complications, has not been previously reported.Between 8/2011 and 4/2016, 86 SCD patients who received their routine care at our institution were referred to the Blood & Marrow Transplant Clinic. Sixteen patients received a HSCT from an HLA-match related donor during this time period. Reasons for not proceeding to transplantation in the 70 patients included lack of an HLA-matched related donor in 36 (51%), patient/family declining in 21 (30%), insurance denial in 11 (16%), and the presence of RBC antibodies to potential donors in 2 (3%) patients. We compared health care utilization patterns between 1) 1-year pre-HSCT vs. 1- and 2-years post-HSCT in 16 transplanted SCD adults and 2) 16 transplanted vs. 70 non-transplanted SCD patients at 1- and 2-years from the time of HSCT or referral. Comparisons of linear variables and categorical variables were performed using the Kruskal-Wallis and Chi-square test, respectively.In the 16 SCD patients who met standard transplant eligibility criteria and underwent HSCT, the median age at the time of HSCT was 33 years (interquartile range [IQR], 24 - 34 years), 56% were male, and 94% were HbSS genotype. Treatment prior to HSCT was hydroxyurea in 10 (63%), chronic red blood cell (RBC) transfusion therapy in 5 (31%), and no disease modifying therapy in 1 (6%) patient. Thirteen of 16 (81%) transplanted SCD patients maintained a stable graft. Emergency room (ER) visits were lower 1-year and 2-year post-HSCT compared to 1-year pre-HSCT (P=0.03) (Table 1). In the 2nd year post-HSCT, ER visits, hospital length of stay, RBC transfusion requirements, and rates of documented infections were all lower compared to 1-year pre-HSCT (P<0.03).We then compared health care utilization patterns between the 16 SCD patients that underwent HSCT vs. the 70 SCD patients that were not transplanted. The HSCT and non-HSCT patients were similar with respect to median age (33 vs. 31 years old; P=0.2), gender (35% vs. 56% male, P=0.1), number of eligibility criteria met for HSCT (PMID: 24319206) (2 for each group; P=0.4) and SCD genotype (80% vs. 94% HbSS genotype, P=0.4), respectively. During the first year after transplant or of observation, we observed lower rates of emergency room visits but a greater number of inpatient hospital days in the HSCT vs. no HSCT groups (Figure 1). During the second year, both the number of emergency room visits and the number of inpatient hospital days were lower in the HSCT vs. the no HSCT patients (Figure 1).In conclusion, we demonstrate that allogeneic HSCT leads to lower health care utilization by the second year post-HSCT in adults with SCD. These results support the role for HSCT to lower the morbidity, health care burden and costs associated with SCD and should encourage universal insurance coverage for HSCT in adults with SCD. [Display omitted] DisclosuresPatel:Celgene: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Janssen: Honoraria. Khan:Teva: Speakers Bureau.

Outcomes of clients in need of intensive team care in Flexible Assertive Community Treatment in Sweden

Background: Flexible Assertive Community Treatment (Flexible ACT) has been implemented in Sweden during recent years due to increasing interest in integrated services for people with severe mental illness. To date, few studies have been done on Flexible ACT effectiveness.Aims: The overall aim of this study was to explore the extent to which clients assigned to the Flexible ACT board for ACT intensive care were stabilized with improved everyday functioning, social outcomes, and changes in healthcare use.Methods: Ninety-three participants with psychosis, in need of ACT from six newly started Flexible ACT teams, were included. Data were collected using the Social Outcome Index scale (SIX), Practical and Social Functioning Scale, and a healthcare usage questionnaire.Results: There was a significant positive change in everyday functioning and in the SIX-item ‘friendship’ at 18-months follow-up. A positive correlation was also found between everyday functioning and the SIX-item ‘friendship’ and a negative correlation between duration of ACT and everyday functioning. A significant increase in number of inpatient hospital days and psychiatric outpatient visits also occurred.Conclusion: Clients with psychosis who need ACT may benefit from Flexible ACT through improved social functioning. Being involved in meaningful activities and supported by others are key aspects of recovering from mental illness and are enhanced by Flexible ACT.

Multicenter Trial of Rivaroxaban for Early Discharge of Pulmonary Embolism From the Emergency Department (MERCURY PE): Rationale and Design.

Traditionally, patients with pulmonary embolism (PE) are admitted from the emergency department and treated with low-molecular-weight heparin followed by warfarin. Several studies now demonstrate that it is possible to identify low-risk PE patients that can safely be treated as outpatients. The advent of the direct-acting oral anticoagulants such as rivaroxaban has made it easier than ever to manage patients outside of the hospital. This article describes the design of a randomized controlled trial aimed at testing the hypothesis that low-risk PE patients can be safely and effectively managed at home using rivaroxaban, resulting in fewer days of hospitalization than standard-of-care treatment. We have initiated a multicenter, open-label, randomized clinical trial in which low-risk adult PE patients (identified by the Hestia criteria) are randomized to outpatient management with oral rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily for 90 days versus standard care, determined by the treating physician and based on local practices. The primary clinical endpoint will be the total number of inpatient hospital days (including the index admission) for venous thromboembolic or bleeding-related events during the first 30 days after randomization. A total of 150 subjects per group will provide 82% power to detect a difference of 1 day or greater in the primary outcome. Patient enrollment is ongoing at present in 45 of 60 planned sites. No interim analysis is planned and the study is being monitored by a data safety management board. The MERCURY PE study is designed to test the hypothesis that outpatient management of low-risk PE patients with rivaroxaban reduces the number of hospitalization days from venous thromboembolism and bleeding compared with standard care. This article describes the rationale and methodology for this study.

Spine Surgery under Spinal Anaesthesia

Introduction Spine surgery like discectomy, decompression and lumbar fusions are most commonly performed under general anesthesia, which can be associated with several perioperative morbidities including prone positioning morbidities (for example ocular complications especially in patients with single precious eye), nausea, vomiting, lung atelectasis, pulmonary aspiration, prolonged post-anesthesia recovery and special complications for high risk patients as those with chest problems and or liver problems. It may be possible to reduce general anesthesia complications rate if the procedure is performed under spinal anesthesia. This may also remarkably reduce postoperative pain. Material and Methods To investigate the safety and efficacy of spinal anesthesia in elective lumbar spine surgeries. A prospective study evaluating the relative morbidities associated with Spinal anesthesia for lumbar and lower dorsal spine surgery. 174 patients scheduled for spine surgery. 172 patients scheduled for lumbar surgery(revision posterior spinal fusion 11 patients, removal of instrumentation 5 patients, vertebroplasty 25 patients, 15 patients for soft TLIF, 23 patients for Posterolateral fusion, 26 for TLIF, 37 for decompression and 30 patients for discectomies). Two patients scheduled for dorsal 10–11–12 decompression and posterolateral fusion. The clinical outcome was determined by the presence of postoperative pain, the absence of anesthesia-related complications, and the overall postoperative recovery.patients satisfaction was evaluated by asking questions about their experience. 174 patients agreed to receive spinal anesthesia for the procedure. Recorded data for all patients included: age; total surgical time; occurrence of nausea, vomiting, atelectasis, or cardiopulmonary complication; ability to arise out of bed on the day of surgery; and the total number of inpatient hospital days. Postoperative pain and satisfaction were assessed Formularbeginn. Results There were a total of 174 patients, with a mean age range from (16–75 years). The patients undergoing spine surgery with spinal anesthesia.operative time range from (45–300 minutes) The spinal anesthesia were different with respect to the expected surgical time, pain assessed with a linear visual analogue scale, hospital stay, or the likelihood of arising out of bed on the day of surgery. There were no major cardiopulmonary complications. Patients with spinal anesthesia had no nausea and vomiting.spinal anaesia produce hypotension and decrease blood loss. These patients were able to help us at positioning at the beginning of surgery. Intraoperative talks or interactions was possible. Blood loss range(50cc-1200cc) We need to inject extra dose during surgery in 7 cases and only one 3 level revision lumbar case last for 5 hours we need to convert after 3 hours to general anesthesia. Postoperative patient can eat immediately. Delayed assessment of the full neural recovery is the only drawback. Conclusions Lumbar spine anesthesia as an alternative to general anesthesia in spine surgery has shown less blood loss, better surgical field better postoperative pain control, less postoperative nausea and vomiting and less positioning complications.

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P149 Effect of macitentan on pulmonary arterial hypertension-related hospitalisations: results from the randomised controlled SERAPHIN trial

Introduction and objectivesMacitentan, a novel dual endothelin receptor antagonist with sustained receptor binding, significantly reduced the risk of morbidity and mortality in pulmonary arterial hypertension (PAH) patients in the SERAPHIN...

DISEASE, PATIENT AND HEALTHCARE SYSTEM LEVEL PREDICTORS OF ACCUMULATED INPATIENT DAYS AND HOME CARE USE FOR METASTATIC GASTRIC CANCER PATIENTS

IntroductionHome care has been proposed as a means of reducing costs in palliative care by decreasing inpatient stay without impacting quality of clinical care. Predictors of major cost drivers for...

Endoscopic Sinus Surgery in Adults With Cystic Fibrosis

To ascertain the effect of endoscopic sinus surgery (ESS) on lung function, intravenous (IV) antibiotic use, and hospitalization in adults with cystic fibrosis (CF). Retrospective analysis. Tertiary care center. Fifteen adults with a diagnosis of CF undergoing ESS between March 1, 2006, and June 31, 2008. Twelve-month preoperative and 12-month postoperative pulmonary function testing (forced vital capacity [FVC] and forced expired volume in 1 second [FEV1]), number of IV antibiotic courses, total number of days of intravenous antibiotic use, and number of inpatient hospital days (IHDs) were assessed. Twenty-two adults with CF underwent ESS; 15 patients had adequate data for evaluation. No significant differences were found between mean preoperative and postoperative FEV1 (61.3% vs 59.5%; P = .41) or FVC (76.4% vs 76.1%; P = .97) or between best preoperative and postoperative FEV1 (67.4% vs 67.0%; P = .95) or FVC (84.2% vs 83.0%; P = .86) (paired samples t test). The number of IV antibiotic courses and the total number of days of IV antibiotic use did not differ between the preoperative and postoperative periods (Wilcoxon signed rank test P = .61 and P = .10, respectively). However, the number of IHDs was significantly lower in the 1-year postoperative period (36.7 days) vs the 1-year preoperative period (59.1 days) (Wilcoxon signed rank test, z = -2.20, P = .03). This preliminary study of ESS in adult CF patients indicates significant reduction in the number of IHDs in the postoperative period. However, there is no evidence that ESS improved lung function or the need for IV antibiotics.

Education of the Pediatric Patient With Asthma: A Literature Review

Pediatric asthma afflicts nearly 9 million children in the United States and is considered one of the most chronic conditions of childhood. According to The Children's Health Fund (2006), children with asthma have 65% more acute care visits, three times as many prescriptions, and double the number of inpatient hospital days than the general pediatric population. In addition, the health care costs for children diagnosed with asthma are 88% higher than for children who do not have asthma.

Nephrology Literature Watch

Nephrology Literature Watch