Outpatient Encounters Research Articles

Management of modifiable risk factors and comorbidities in atrial fibrillation: suggestions for improvement from a patient perspective

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): SLL Region Stockholm Innovation SLL Region Stockholm Klinisk Forskare. Background In patients with atrial fibrillation (AF), improved management of modifiable risk factors, unhealthy lifestyle and concomitant diseases is highly recommended by guidelines, in particular if rhythm control is desired. Yet, many AF patients have suboptimal management of risk factors and comorbidities. There is a lack of understanding how patients can be better aided to achieve these goals in clinical practice. Digital health solutions may offer support in this matter. Purpose To identify what patients with atrial fibrillation would find important in a digital tool aimed at optimization of modifiable risk factors and comorbidities. Methods This is a qualitative, descriptive study based on semi-structured interviews that were analyzed by manifest content analysis. 16 AF patients with recent in- or outpatient encounters were included (age 68 (52-78) years; 43% female; BMI 29.5 (20.4-35.8) kg/m2; paroxysmal/persistent AF (50%/50%); AF duration 7 (0-22) years). Four semi-structured focus-group interviews were conducted. Study results were intended to inform the development of a digital tool aimed to support risk factor and comorbidity optimization in patients scheduled for rhythm control interventions. Results Relevant comorbidities were hypertension (88%), heart failure (25%), diabetes mellitus type 2 (19%) and ischemic heart disease (13%). Only 19% stated that they were satisfied with their current level of physical activity and 19% were satisfied with their current eating habits. The participants’ suggestions were summarized into three main categories. First, person-centered information is essential, meaning that information should be customized, conveyed in an appropriate tone and include practical tips. Second, there is an unmet need for help with managing lifestyle habits in a way that is easily applicable in everyday life, and patients desire help with creating habits. Third, regular communication is necessary including inspirational reminders and motivational feedback. Conclusions From a patient perspective, person-centered information, practical help with managing lifestyle habits, and regular communication are considered essential in helping to optimize treatment of comorbidities and associates risk factors associated to lifestyle. This can, at least in part, be done digitally and should be implemented more in standard care to improve outcomes and reduce cost.

A Comprehensive Examination of Pediatric Behavioral Health Service Demand and Utilization in a Large, Academic Health System from 2019 to 2021.

Studies of the effects of COVID-19 on youth suggest a worsening in mental health globally. We performed a retrospective analysis of data from January 2019-November 2021 for all outpatient referrals, as well as outpatient, inpatient, and emergency department (ED) encounters for behavioral health (BH) reasons in children aged < 18 in a large academic health system in the United States. Mean weekly rates of outpatient psychiatry referrals, outpatient psychiatry visits, ED visits, and inpatient admissions for BH reasons were compared between pre-pandemic and pandemic periods. The average weekly rate of ambulatory referrals (8.0 ± 0.33 to 9.4 ± 0.31) and completed appointments (194.2 ± 0.72 to 213.1 ± 0.71) significantly increased during the pandemic, driven largely by teenagers. The weekly average of ED pediatric encounters for BH did not increase during the pandemic, although the percentage of all pediatric ED encounters that were for BH did increase from 2.6 to 4.1% (p < 0.001). Length of stay for pediatric BH ED patients increased from 1.59 ± 0.09 days pre-pandemic to 1.91 ± 0.11 days post-pandemic (p < 0.0001). Inpatient admissions for BH reasons overall decreased during the pandemic, due to a decrease in inpatient psychiatric bed capacity. However, the weekly percentage of inpatient hospitalizations for BH reasons that occurred on medical units increased during the pandemic (15.2% ± 2.8-24.6% ± 4.1% (p = 0.0006)). Taken together, our data suggest the COVID-19 pandemic had varying degrees of impact, depending on the setting of care.

(474) Trends and Costs of Ambulatory vs Inpatient Penile Prosthesis Placement

Abstract Introduction Current literature is limited in assessing nationwide trends of penile prosthesis (PP) placement in the United States largely due to a lack of data on outpatient PP placement. Particularly no nationwide comparison of ambulatory surgery center (ASC) versus inpatient hospital (IH) PP placement has been published. Objective Our objective is to determine the trends of PP placement in ASCs vs IHs utilizing representative nationwide data. Additionally, we examined patient demographics that are associated with the setting for PP placement. Methods Inpatient and outpatient encounters for PP placement between 2016 and 2019 were analyzed using data from the Nationwide Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS) from the Healthcare Cost and Utilization Project (HCUP). These are the largest publicly available inpatient and ambulatory surgery databases available in the United States. PP operations were identified by CPT and ICD-10-PCS codes. Subsequent analysis was performed using the established weighting provided by the HCUP, which utilizes stratified cluster sampling to create national estimates. Comparisons of demographics were performed using t-tests and chi-square tests with a p-value for significance &amp;lt;0.05. Results Over the study period, there were 67,722 PP placements in the United States. The percentage placed in ASCs was 93.1%. In 2016, 16,290 PP placements occurred, of which 92.3% were placed in ASCs. Comparatively in 2019, there was a 7.3% increase (17,473) in the number of PP placements, with 94.5% placed in ASCs (p&amp;lt;0.01). Over the study period, 33,008 PP placements were performed in the South (93.8% ASCs), 12,481 in the Midwest (94.6% ASCs), 12,192 in the Northeast (92.4% ASCs), and 10,040 in the West (90.1% ASCs, p&amp;lt;0.01). The average age of patients receiving a PP placement was 64.4 in ASCs compared with 62.5 in IHs (p&amp;lt;0.01). The average cost associated with PP placement in ASCs was $25,935, about half the cost of inpatient settings, which averaged $51,594 (p&amp;lt;0.01). Of all PP implants, the primary payer was medicare for 57.1% (38,660; 93.1% ASCs), medicaid for 4.4% (2980; 86.6% ASCs), private for 33.6% (22,778; 94.3% ASCs), and self-pay for 1.1% (768; 90.9% ASCs, p &amp;lt;0.01). Conclusions Our results suggest that the number of PP placements is consistently rising each year, with an increasing majority of PP placements performed in ASCs. The procedure costs roughly half on average when performed in ASCs compared to IHs. Further investigation is needed to compare complication rates and outcomes of PP placements in ASC versus IH. Disclosure No

Overall and Telehealth Addiction Treatment Utilization by Age, Race, Ethnicity, and Socioeconomic Status in California After COVID-19 Policy Changes

Addiction treatment rapidly transitioned to a primarily telehealth modality (telephone and video) during the COVID-19 pandemic, raising concerns about disparities in utilization. To examine whether there were differences in overall and telehealth addiction treatment utilization after telehealth policy changes during the COVID-19 pandemic by age, race, ethnicity, and socioeconomic status. This cohort study examined electronic health record and claims data from Kaiser Permanente Northern California for adults (age ≥18 years) with drug use problems before the COVID-19 pandemic (from March 1, 2019, to December 31, 2019) and during the early phase of the COVID-19 pandemic (March 1, 2020, to December 31, 2020; hereafter referred to as COVID-19 onset). Analyses were conducted between March 2021 and March 2023. The expansion of telehealth services during COVID-19 onset. Generalized estimating equation models were fit to compare addiction treatment utilization during COVID-19 onset with that before the COVID-19 pandemic. Utilization measures included the Healthcare Effectiveness Data and Information Set of treatment initiation and engagement (including inpatient, outpatient, and telehealth encounters or receipt of medication for opioid use disorder [OUD]), 12-week retention (days in treatment), and OUD pharmacotherapy retention. Telehealth treatment initiation and engagement were also examined. Differences in changes in utilization by age group, race, ethnicity, and socioeconomic status (SES) were examined. Among the 19 648 participants in the pre-COVID-19 cohort (58.5% male; mean [SD] age, 41.0 [17.5] years), 1.6% were American Indian or Alaska Native; 7.5%, Asian or Pacific Islander; 14.3%, Black; 20.8%, Latino or Hispanic; 53.4%, White; and 2.5%, unknown race. Among the 16 959 participants in the COVID-19 onset cohort (56.5% male; mean [SD] age, 38.9 [16.3] years), 1.6% were American Indian or Alaska Native; 7.4%, Asian or Pacific Islander; 14.6%, Black; 22.2%, Latino or Hispanic; 51.0%, White; and 3.2%, unknown race. Odds of overall treatment initiation increased from before the COVID-19 pandemic to COVID-19 onset for all age, race, ethnicity, and SES subgroups except for patients aged 50 years or older; patients aged 18 to 34 years had the greatest increases (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.40). Odds of telehealth treatment initiation increased for all patient subgroups without variation by race, ethnicity, or SES, although increases were greater for patients aged 18 to 34 years (aOR, 7.17; 95% CI, 6.24-8.24). Odds of overall treatment engagement increased (aOR, 1.13; 95% CI, 1.03-1.24) without variation by patient subgroups. Retention increased by 1.4 days (95% CI, 0.6-2.2 days), and OUD pharmacotherapy retention did not change (adjusted mean difference, -5.2 days; 95% CI, -12.7 to 2.4 days). In this cohort study of insured adults with drug use problems, there were increases in overall and telehealth addiction treatment utilization after telehealth policies changed during the COVID-19 pandemic. There was no evidence that disparities were exacerbated, and younger adults may have particularly benefited from the transition to telehealth.

The Evolution of Primary Care Telehealth Disparities During COVID-19: Retrospective Cohort Study.

Telehealth has become widely used as a novel way to provide outpatient care during the COVID-19 pandemic, but data about telehealth use in primary care remain limited. Studies in other specialties raise concerns that telehealth may be widening existing health care disparities, requiring further scrutiny of trends in telehealth use. Our study aims to further characterize sociodemographic differences in primary care via telehealth compared to in-person office visits before and during the COVID-19 pandemic and determine if these disparities changed throughout 2020. We conducted a retrospective cohort study in a large US academic center with 46 primary care practices from April-December 2019 to April-December 2020. Data were subdivided into calendar quarters and compared to determine evolving disparities throughout the year. We queried and compared billed outpatient encounters in General Internal Medicine and Family Medicine via binary logic mixed effects regression model and estimated odds ratios (ORs) with 95% CIs. We used sex, race, and ethnicity of the patient attending each encounter as fixed effects. We analyzed socioeconomic status of patients in the institution's primary county based on the patient's residence zip code. A total of 81,822 encounters in the pre-COVID-19 time frame and 47,994 encounters in the intra-COVID-19 time frame were analyzed; in the intra-COVID-19 time frame, a total of 5322 (11.1%) of encounters were telehealth encounters. Patients living in zip code areas with high utilization rate of supplemental nutrition assistance were less likely to use primary care in the intra-COVID-19 time frame (OR 0.94, 95% CI 0.90-0.98; P=.006). Encounters with the following patients were less likely to be via telehealth compared to in-person office visits: patients who self-identified as Asian (OR 0.74, 95% CI 0.63-0.86) and Nepali (OR 0.37, 95% CI 0.19-0.72), patients insured by Medicare (OR 0.77, 95% CI 0.68-0.88), and patients living in zip code areas with high utilization rate of supplemental nutrition assistance (OR 0.84, 95% CI 0.71-0.99). Many of these disparities persisted throughout the year. Although there was no statistically significant difference in telehealth use for patients insured by Medicaid throughout the whole year, subanalysis of quarter 4 found encounters with patients insured by Medicaid were less likely to be via telehealth (OR 0.73, 95% CI 0.55-0.97; P=.03). Telehealth was not used equally by all patients within primary care throughout the first year of the COVID-19 pandemic, specifically by patients who self-identified as Asian and Nepali, insured by Medicare, and living in zip code areas with low socioeconomic status. As the COVID-19 pandemic and telehealth infrastructure change, it is critical we continue to reassess the use of telehealth. Institutions should continue to monitor disparities in telehealth access and advocate for policy changes that may improve equity.

Structure and integration of specialty palliative care in three NCI-designated cancer centers: a mixed methods case study

IntroductionEarly access to specialty palliative care is associated with better quality of life, less intensive end-of-life treatment and improved outcomes for patients with advanced cancer. However, significant variation exists in implementation and integration of palliative care. This study compares the organizational, sociocultural, and clinical factors that support or hinder palliative care integration across three U.S. cancer centers using an in-depth mixed methods case study design and proposes a middle range theory to further characterize specialty palliative care integration.MethodsMixed methods data collection included document review, semi-structured interviews, direct clinical observation, and context data related to site characteristics and patient demographics. A mixed inductive and deductive approach and triangulation was used to analyze and compare sites’ palliative care delivery models, organizational structures, social norms, and clinician beliefs and practices.ResultsSites included an urban center in the Midwest and two in the Southeast. Data included 62 clinician and 27 leader interviews, observations of 410 inpatient and outpatient encounters and seven non-encounter-based meetings, and multiple documents. Two sites had high levels of “favorable” organizational influences for specialty palliative care integration, including screening, policies, and other structures facilitating integration of specialty palliative care into advanced cancer care. The third site lacked formal organizational policies and structures for specialty palliative care, had a small specialty palliative care team, espoused an organizational identity linked to treatment innovation, and demonstrated strong social norms for oncologist primacy in decision making. This combination led to low levels of specialty palliative care integration and greater reliance on individual clinicians to initiate palliative care.ConclusionIntegration of specialty palliative care services in advanced cancer care was associated with a complex interaction of organization-level factors, social norms, and individual clinician orientation. The resulting middle range theory suggests that formal structures and policies for specialty palliative care combined with supportive social norms are associated with greater palliative care integration in advanced cancer care, and less influence of individual clinician preferences or tendencies to continue treatment. These results suggest multi-faceted efforts at different levels, including social norms, may be needed to improve specialty palliative care integration for advanced cancer patients.

Healthcare Utilization After Respiratory Tuberculosis: A Controlled Interrupted Time Series Analysis.

Despite data suggesting elevated morbidity and mortality among people who have survived tuberculosis disease, the impact of respiratory tuberculosis on healthcare utilization in the years following diagnosis and treatment remains unclear. Using linked health administrative data from British Columbia, Canada, we identified foreign-born individuals treated for respiratory tuberculosis between 1990 and 2019. We matched each person with up to four people without a tuberculosis diagnosis from the same source cohort using propensity score matching. Then, using a controlled interrupted time series analysis, we measured outpatient physician encounters and inpatient hospital admissions in the 5 years following respiratory tuberculosis diagnosis and treatment. We matched 1216 individuals treated for respiratory tuberculosis to 4864 non-tuberculosis controls. Immediately following the tuberculosis diagnostic and treatment period, the monthly rate of outpatient encounters in the tuberculosis group was 34.0% (95% confidence interval [CI]: 30.7%, 37.2%) higher than expected, and this trend was sustained for the duration of the post-tuberculosis period. The excess utilization represented an additional 12.2 (95% CI: 10.6, 14.9) outpatient encounters per person over the post-tuberculosis period, with respiratory morbidity a large contributor to the excess healthcare utilization. Results were similar for hospital admissions, with an additional 0.4 (95% CI: .3, .5) hospital admissions per person over the post-tuberculosis period. Respiratory tuberculosis appears to have long-term impacts on healthcare utilization beyond treatment. These findings underscore the need for screening, assessment, and treatment of post-tuberculosis sequelae, as it may provide an opportunity to improve health and reduce resource use.

Impact of the COVID-19 pandemic on the management of risk factors in patients with stable atherosclerotic vascular disease

BackgroundEffective control of risk factors in patients with ASCVD is important to reduce recurrent cardiovascular events. However, many ASCVD patients do not have their risk factors controlled, and this may have worsened during the COVID-19 pandemic. MethodsWe retrospectively evaluated risk factor control among 24,760 ASCVD patients who had at least 1 outpatient encounter both pre-pandemic and during the first year of the pandemic. Risk factors were uncontrolled if the blood pressure (BP) ≥ 130/80 mm Hg, LDL-C ≥ 70 mg/dL, HgbA1c ≥ 7 for diabetic patients, and patients were current smokers. ResultsDuring the pandemic, many patients had their risk factors unmonitored. BP control worsened (BP ≥ 130/80 mmHg, 64.2 vs 65.7%; p = 0.01), while lipid management improved with more patients on a high-intensity statin (38.9 vs 43.9%; p<0.001) and more achieving an LDL-C < 70 mg/dL, less patients were smoking (7.4 vs 6.7%; p<0.001), and diabetic control was unchanged pre vs during the pandemic. Black (OR 1.53 [1.02–2.31]) and younger aged patients (OR 1.008 [1.001–1.015]) were significantly more likely to have missing or uncontrolled risk factors during the pandemic. ConclusionsDuring the pandemic risk factors were more likely to be unmonitored. While measured blood pressure control worsened, lipid control and smoking improved. Although some cardiovascular risk factor control improved during the COVID-19 pandemic, overall control of cardiovascular risk factors in patients with ASCVD was suboptimal, especially in Black and younger patients. This puts many ASCVD patients at increased risk of a recurrent cardiovascular event.

Use telehealth as needed: telehealth substitutes in-person primary care and associates with the changes in unplanned events and follow-up visits

BackgroundTelehealth rapidly expanded since the outbreak of the COVID-19 pandemic. This study aims to understand how telehealth can substitute in-person services by 1) estimating the changes in non-COVID emergency department (ED) visits, hospitalizations, and care costs among US Medicare beneficiaries by visit modality (telehealth vs. in-person) during the COVID-19 pandemic relative to the previous year; 2) comparing the follow-up time and patterns between telehealth and in-person care.MethodsA retrospective and longitudinal study design using US Medicare patients 65 years or older from an Accountable Care Organization (ACO). The study period was April-December 2020, and the baseline period was March 2019 – February 2020. The sample included 16,222 patients, 338,872 patient-month records and 134,375 outpatient encounters. Patients were categorized as non-users, telehealth only, in-person care only and users of both types. Outcomes included the number of unplanned events and costs per month at the patient level; number of days until the next visit and whether the next visit happened within 3-, 7-, 14- and 30-days at the encounter level. All analyses were adjusted for patient characteristics and seasonal trends.ResultsBeneficiaries who used only telehealth or in-person care had comparable baseline health conditions but were healthier than those who used both types of services. During the study period, the telehealth only group had significantly fewer ED visits/hospitalizations and lower Medicare payments than the baseline (ED 13.2, 95% CI [11.6, 14.7] vs. 24.6 per 1,000 patients per month and hospitalization 8.1 [6.7, 9.4] vs. 12.7); the in-person only group had significantly fewer ED visits (21.9 [20.3, 23.5] vs. 26.1) and lower Medicare payments, but not hospitalizations; the both-types group had significantly more hospitalizations (23.0 [21.4, 24.6] vs. 17.8). Telehealth was not significantly different from in-person encounters in number of days until the next visit (33.4 vs. 31.2 days) or the probabilities of 3- and 7-day follow-up visits (9.2 vs. 9.3% and 21.8 vs.23.5%).ConclusionsPatients and providers treated telehealth and in-person visits as substitutes and used either depending on medical needs and availability. Telehealth did not lead to sooner or more follow-up visits than in-person services.

PO-04-210 NEW-ONSET DIABETES SCREENING USING ARTIFICIAL INTELLIGENCE-ENHANCED ELECTROCARDIOGRAM

Diabetes has a long asymptomatic period which can remain undiagnosed for years. Glycated hemoglobin (HbA1c) enables the discovery of asymptomatic diabetes. Yet, undiagnosed diabetes is present in 23.0% of all US adults with Diabetes and 3.4% of all US adults. American Diabetes Association (ADA) guidlines promote the use of risk tests that help identify candidates for diagnostic testing. To develop and evaluate an artificial intelligence (AI)-enhanced electrocardiogram algorithm (ECGAI-DM) for screening of Diabetes. We trained a neural network to estimate HbA1c using a 12-lead ECG and readily available demographics (ECG model), and evaluated its ability to screen for Diabetes in a complete outpatient population. The dataset comprised of patients (aged ≥18 years) with paired 12-lead, 10-second ECG and HbA1c test acquired during an outpatient encounter. Our primary outcome was the performance of the AI-enhanced ECG at classifying new-onset diabetes (HbA1c ≥ 6.5 in patients without a prior history of diabetes), which was assessed using the area under the receiver operator curve (AUC) and positive predictive value (PPV) at the sensitivity defined by the ADA risk test, with 95% bootstrap CIs. Population bias was addressed by reconstruction of a pseudopopulation with adjusted individual patient weights. We trained on 198,857 ECGs from 160,788 patients, and our test set comprised 34,106 ECGs from 30,593 patients, recorded between January 1, 2013 and September 17, 2021. The prevalence of Diabetes (HbA1c ≥ 6.5) was 4.9%. The ECGAI-DM significantly outperformed the ADA Risk test (AUC, 0.80 [95% CI, 0.79-0.81] vs. AUC, 0.68 [95% CI, 0.68-0.69]; p-value <0.001). The ECGAI-DM model restricted to using a single lead (Lead-I) outperformed the ADA risk test as well (AUC, 0.78 [95% CI, 0.78-0.79] vs. 0.68 [95% CI, 0.68-0.69]; p-value <0.001). Patients with false positive prediction by ECGAI-DM had a 3-fold risk for Diabetes over a 1 year follow up as compared to the true negative population, suggesting unmasking of latent high risk. In a separate test set, ECGAI-DM significantly outperformed 2 human Cardiologists (AUC 0.82 vs. 0.61, p<0.001) assessed on a class balanced 100 randomly sampled ECGs. An AI-enhanced ECG can automate the screening of patients for Diabetes with fewer false positives than questionnaire-based assessment. This also applies to single-lead ECGs commonly found on wearable devices, which suggests an avenue for community-wide opportunistic Diabetes screening.

Prevalence, Severity, and Co-Occurrence of SPPADE Symptoms in 31,866 Patients With Cancer.

To examine the prevalence, severity, and co-occurrence of SPPADE symptoms as well as their association with cancer type and patient characteristics. The SPPADE symptoms (sleep disturbance, pain, physical function impairment, anxiety, depression, and low energy /fatigue) are prevalent, co-occurring, and undertreated in oncology and other clinical populations. Baseline SPPADE symptom data were analyzed from the E2C2 study, a stepped wedge pragmatic, population-level, cluster randomized clinical trial designed to evaluate a guideline-informed symptom management model targeting the six SPPADE symptoms. Symptom prevalence and severity were measured with a 0-10 numeric rating (NRS) scale for each of the six symptoms. Prevalence of severe (NRS ≥ 7) and potential clinically relevant (NRS ≥ 5) symptoms as well as co-occurrence of clinical symptoms were determined. Distribution-based methods were used to estimate the minimally important difference (MID). Associations of cancer type and patient characteristics with a SPPADE composite score were analyzed. A total of 31,886 patients were assessed for SPPADE symptoms prior to, during, or soon after an outpatient medical oncology encounter. The proportion of patients with a potential clinically relevant symptom ranged from 17.5% for depression to 33.4% for fatigue. Co-occurrence of symptoms was high, with the proportion of patients with three or more additional clinically relevant symptoms ranging from 45.2% for fatigue to 68.6% for depression. The summed SPPADE composite score demonstrated good internal reliability (Cronbach's alpha of 0.86), with preliminary MID estimates of 4.1-4.3. Symptom burden differed across several types of cancer but was generally similar across most sociodemographic characteristics. The high prevalence and co-occurrence of SPPADE symptoms in patients with all types of cancer warrants clinical approaches that optimize detection and management.

Linked Patient and Provider Impressions of Outpatient Teleneurology Encounters.

Teleneurology is common in clinical practice partly due to the SARS CoV-2 pandemic. Impressions about teleneurology from patients and providers alike are generally favorable; some of the reported benefits include ease of access to specialized health care, savings of time and money, and similar quality of care as an in-person visit. However, comparisons between patient and provider impressions about the same teleneurology encounter have not been described. In this study, we describe patient impressions about a teleneurology encounter and evaluate concordance with provider impressions about the same encounter. Patients and providers at the University of Pennsylvania Hospital Neurology Department were surveyed about their impressions of teleneurology between April 27, 2020, and June 16, 2020. A convenience sample of patients, whose providers completed a questionnaire, were contacted by telephone to solicit their impressions about the same encounter. Unique questionnaires for patients and providers focused on similar themes, such as adequacy of technology, assessment of history obtained, and overall quality of the visit. Summaries of patient responses are reported with the raw percent agreement between patients and providers for similar questions. One hundred thirty-seven patients completed the survey; 64 (47%) were male and 73 (53%) were female. Sixty-six (47%) patients had a primary diagnosis of PD, 42 (30%) a non-PD/parkinsonism movement disorder, and 29 (21%) a nonmovement disorder neurologic disease. One hundred one (76%) were established patient visits and 36 (26%) were new patient visits. Provider responses from 8 different physicians were included. Most of the patients responded that the ease of joining their visit, their comfort engaging with their physicians during their visit, understanding their plan of care after their visit, and the quality of care from their teleneurology visit were satisfactory. Patients and providers agreed about their impressions of the quality of the history obtained (87% agreement), patient-provider relationship (88% agreement), and overall quality of their experience (70% agreement). Patients had favorable impressions about their clinical experience with teleneurology and expressed an interest in incorporating telemedicine visits into their ongoing care. Patients and providers were highly concordant for the history obtained, patient-provider relationship, and overall quality.

The impact of COVID-19 on psychiatric clinical encounters among low-income racially-diverse children.

There is a lack of longitudinal data to examine the impact of COVID-19 on all types of clinical encounters among United States, underrepresented BIPOC (Black, Indigenous, and people of color), children. This study aims to examine the changes in all the outpatient clinical encounters during the pandemic compared to the baseline, with particular attention to psychiatric encounters and diagnoses. This study analyzed 3-year (January 2019 to December 2021) longitudinal clinical encounter data from 3,394 children in the Boston Birth Cohort, a US urban, predominantly low-income, Black and Hispanic children. Outcomes of interest were completed outpatient clinical encounters and their modalities (telemedicine vs. in person), including psychiatric care and diagnoses, primary care, emergency department (ED), and developmental and behavioral pediatrics (DBP). The study children's mean (SD) age is 13.9 (4.0) years. Compared to 2019, psychiatric encounters increased by 38% in 2020, most notably for diagnoses of adjustment disorders, depression, and post-traumatic stress disorders (PTSD). In contrast, primary care encounters decreased by 33%, ED encounters decreased by 55%, and DBP care decreased by 16% in 2020. Telemedicine was utilized the most for psychiatric and DBP encounters and the least for primary care encounters in 2020. A remarkable change in 2021 was the return of primary care encounters to the 2019 level, but psychiatric encounters fluctuated with spikes in COVID-19 case numbers. Among this sample of US BIPOC children, compared to the 2019 baseline, psychiatric encounters increased by 38% during 2020, most notably for the new diagnoses of adjustment disorder, depression, and PTSD. The 2021 data showed a full recovery of primary care encounters to the baseline level but psychiatric encounters remained sensitive to the pandemic spikes. The long-term impact of the pandemic on children's mental health warrants further investigation.

Glycemic Control Over Multiple Decades and Dementia Risk in People With Type 2 Diabetes

The levels of glycemic control associated with the lowest risk of dementia in people with type 2 diabetes are unknown. This knowledge is critical to inform patient-centered glycemic target setting. To examine the associations between cumulative exposure to various ranges of glycated hemoglobin (HbA1c) concentrations with dementia risk across sex and racial and ethnic groups and the association of current therapeutic glycemic targets with dementia risk. This cohort study included members of the Kaiser Permanente Northern California integrated health care system with type 2 diabetes who were aged 50 years or older during the study period from January 1, 1996, to September 30, 2015. Individuals with fewer than 2 HbA1c measurements during the study period, prevalent dementia at baseline, or less than 3 years of follow-up were excluded. Data were analyzed from February 2020 to January 2023. Time-updated cumulative exposure to HbA1c thresholds. At each HbA1c measurement, participants were categorized based on the percentage of their HbA1c measurements that fell into the following categories: less than 6%, 6% to less than 7%, 7% to less than 8%, 8% to less than 9%, 9% to less than 10%, and 10% or more of total hemoglobin (to convert percentage of total hemoglobin to proportion of total hemoglobin, multiply by 0.01). Dementia diagnosis was identified using International Classification of Diseases, Ninth Revision codes from inpatient and outpatient encounters. Cox proportional hazards regression models estimated the association of time-varying cumulative glycemic exposure with dementia, adjusting for age, race and ethnicity, baseline health conditions, and number of HbA1c measurements. A total of 253 211 participants were included. The mean (SD) age of participants was 61.5 (9.4) years, and 53.1% were men. The mean (SD) duration of follow-up was 5.9 (4.5) years. Participants with more than 50% of HbA1c measurements at 9% to less than 10% or 10% or more had greater risk of dementia compared with those who had 50% or less of measurements in those categories (HbA1c 9% to <10%: adjusted hazard ratio [aHR], 1.31 [95% CI, 1.15-1.51]; HbA1c≥10%: aHR, 1.74 [95% CI, 1.62-1.86]). By contrast, participants with more than 50% of HbA1c concentrations less than 6%, 6% to less than 7%, or 7% to less than 8% had lower risk of dementia (HbA1c<6%: aHR, 0.92 [95% CI, 0.88-0.97]; HbA1c 6% to <7%: aHR, 0.79 [95% CI, 0.77-0.81]; HbA1c 7% to <8%: aHR, 0.93 [95% CI, 0.89-0.97]). In this study dementia risk was greatest among adults with cumulative HbA1c concentrations of 9% or more. These results support currently recommended relaxed glycemic targets for older people with type 2 diabetes.

Effect of Donor Sex on Recipient Mortality in Transfusion

BackgroundConflicting observational evidence exists regarding the association between the sex of red-cell donors and mortality among transfusion recipients. Evidence to inform transfusion practice and policy is limited.MethodsIn this multicenter, double-blind trial, we randomly assigned patients undergoing red-cell transfusion to receive units of red cells from either male donors or female donors. Patients maintained their trial-group assignment throughout the trial period, including during subsequent inpatient and outpatient encounters. Randomization was conducted in a 60:40 ratio (male donor group to female donor group) to match the historical allocation of red-cell units from the blood supplier. The primary outcome was survival, with the male donor group as the reference group.ResultsA total of 8719 patients underwent randomization before undergoing transfusion; 5190 patients were assigned to the male donor group, and 3529 to the female donor group. At baseline, the mean (±SD) age of the enrolled patients was 66.8±16.4 years. The setting of the first transfusion was as an inpatient in 6969 patients (79.9%), of whom 2942 (42.2%) had been admitted under a surgical service. The baseline hemoglobin level before transfusion was 79.5±19.7 g per liter, and patients received a mean of 5.4±10.5 units of red cells in the female donor group and 5.1±8.9 units in the male donor group (difference, 0.3 units; 95% confidence interval [CI], −0.1 to 0.7). Over the duration of the trial, 1141 patients in the female donor group and 1712 patients in the male donor group died. In the primary analysis of overall survival, the adjusted hazard ratio for death was 0.98 (95% CI, 0.91 to 1.06).ConclusionsThis trial showed no significant difference in survival between a transfusion strategy involving red-cell units from female donors and a strategy involving red-cell units from male donors. (Funded by the Canadian Institutes of Health Research; iTADS ClinicalTrials.gov number, NCT03344887.)

Patterns of gender identity data within electronic health record databases can be used as a tool for identifying and estimating the prevalence of gender-expansive people.

Electronic health records (EHRs) within the United States increasingly include sexual orientation and gender identity (SOGI) fields. We assess how well SOGI fields, along with International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes and medication records, identify gender-expansive patients. The study used a data set of all patients that had in-person inpatient or outpatient encounters at an academic medical center in a rural state between December 1, 2018 and February 17, 2022. Chart review was performed for all patients meeting at least one of the following criteria: differences between legal sex, sex assigned at birth, and gender identity (excluding blank fields) in the EHR SOGI fields; ICD-10 codes related to gender dysphoria or unspecified endocrine disorder; prescription for estradiol or testosterone suggesting use of gender-affirming hormones. Out of 123 441 total unique patients with in-person encounters, we identified a total of 2236 patients identifying as gender-expansive, with 1506 taking gender-affirming hormones. SOGI field differences or ICD-10 codes related to gender dysphoria or both were found in 2219 of 2236 (99.2%) patients who identify as gender-expansive, and 1500 of 1506 (99.6%) taking gender-affirming hormones. For the gender-expansive population, assigned female at birth was more common in the 12-29 year age range, while assigned male at birth was more common for those 40 years and older. SOGI fields and ICD-10 codes identify a high percentage of gender-expansive patients at an academic medical center.

Identifying racial disparities in care for children with spastic cerebral palsy: A single center study.

Existing evidence identifies racial and ethnic disparities impacting the prevalence and severity of cerebral palsy (CP). There is a paucity of literature examining the impact on associated treatment. In this retrospective cohort study, an institutional database search identified outpatient encounters for pediatric patients with spastic CP. Additional filters were used to determine treatments received. For each treatment, the proportion of African American (AA) patients receiving treatment was compared to the proportion of Caucasian (C) patients receiving the same treatment. 3,686 children with spastic CP were seen in outpatient clinics associated with an academic tertiary hospital over a 21-year period. There was no significant difference between the proportion of any treatment compared to the entire sample for AA or C patients. In this sample, there was no significant evidence of a racial disparity for AA patients receiving treatments for spasticity. This data is limited by several factors. Further research is needed to determine whether pediatric patients with disabilities are receiving equitable care. Clinicians should consider systematically monitoring their practices to identify areas of bias or inequity in accessing care.

Paediatric obesity: Documentation, screening, and pharmacotherapy in a national cohort.

Multiple organizations have published guidelines for the screening and treatment of obesity and related comorbidities in youth, including the use of anti-obesity medications (AOM). This study aimed to determine which paediatric patients: (1) receive a diagnostic code for obesity; (2) are most likely to be screened for hyperlipidaemia, non-alcoholic fatty liver disease, and type 2 diabetes mellitus; and (3) are most likely to be prescribed AOM. A cohort of 35 898 patients 9 years 4 months to 17 years 6 months of age with a BMI > 30 or greater than the 95th% on three separate outpatient encounters was generated using the TriNetX database. Logistic regression models were used to estimate the associations between demographics in the study population and the likelihood of diagnosis of obesity, screening for comorbidities, and prescription of AOMs. Asian, Black, and Hispanic youths had increased odds of having a diagnosis of obesity and being screened for all three comorbidities. Documentation of obesity was associated with increased odds of screening for all comorbidities. Female sex, documentation of obesity, and higher BMIs were associated with increased odds of being prescribed AOMs. Black and Native American races decreased the likelihood of being prescribed AOM. Management of obesity in terms of documentation of disease, screening for comorbidities, and initiation of AOM continues to fall short of the guidelines put forth by multiple organizations. Race/ethnicity, sex, and BMI correlate with differences in care provided to obese paediatric patients. Further research is needed to identify the barriers to and causes of these disparities.

Major drivers of healthcare system costs and cost variability for routine atrial fibrillation ablation.

Catheter ablation is an effective treatment for atrial fibrillation (AF) but incurs significant financial costs to payers. Reducing variability may improve cost effectiveness. We aimed to measure (1) the components of direct and indirect costs for routine AF ablation procedures, (2) the variability of those costs, and (3) the main factors driving ablation cost variability. Using data from the University of Utah Health Value Driven Outcomes system, we were able to measure direct, inflation-adjusted costs of uncomplicated, routine AF ablation to the healthcare system. Direct costs were considered costs incurred by pharmacy, disposable supplies, patient labs, implants, and other services categories (primarily anesthesia support) and indirect costs were considered within imaging, facility, and electrophysiology lab management categories. A total of 910 patients with 1060 outpatient ablation encounters were included from January 1, 2013, to December 31, 2020. Disposable supplies accounted for the largest component of cost with 44.8 ± 9.7%, followed by other services (primarily anesthesia support) with 30.4 ± 7.7% and facility costs with 16.1 ± 5.6%; pharmacy, imaging, and implant costs each contributed <5%. Direct costs were larger than indirect costs (82.4 ± 5.6% vs 17.6 ± 5.6%). Multivariable regression showed that procedure operator was the primary factor associated with AF ablation overall cost (up to 12% differences depending on operator). Direct costs and other services (primarily anesthesia) drive the majority costs associated with AF ablations. There is significant variability in costs for these routine, uncomplicated AF ablation procedures. The procedure operator, and not patient characteristic, is the main driver for cost variability.

MP48-07 NATIONAL TRENDS OF COMMON FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY PROCEDURES: 2016-2019

You have accessJournal of UrologyCME1 Apr 2023MP48-07 NATIONAL TRENDS OF COMMON FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY PROCEDURES: 2016-2019 Connie Wang, Daniel Schoenfeld, Joseph Marte, and Gregory Joice Connie WangConnie Wang More articles by this author , Daniel SchoenfeldDaniel Schoenfeld More articles by this author , Joseph MarteJoseph Marte More articles by this author , and Gregory JoiceGregory Joice More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To evaluate national trends in settings and charges of common female pelvic medicine and reconstructive surgery (FPMRS) procedures. METHODS: Common FPMRS procedures were identified by Current Procedural Terminology and International Classification of Diseases (10th Revision) Procedure Coding System codes and classified into 3 categories: 1) stress urinary incontinence procedures (SUI-p) 2) pelvic organ prolapse procedures (POP-p) and 3) overactive bladder procedures (OAB-p). Data from inpatient (IP) and outpatient (OP) encounters for included procedures between 2016-2019 were extracted from the Nationwide Inpatient Sample and Nationwide Ambulatory Surgery Sample from the Healthcare Cost and Utilization Project. Stratified cluster sampling was used to create weighted, national estimates. Student t-tests and multivariable linear regression was performed to compare procedural factors. RESULTS: A total of 893,450 weighted procedures were analyzed, of which 9.3% were performed IP and 90.7% were performed OP. Over the study period, there was a 4.3% increase in total number of procedures, and the proportion performed OP increased from 88.1% to 92.5%. Between 2016-2019, there was a 10.6% and 10.5% increase in SUI-p and POP-p performed OP, respectively. Over the study period, proportion of SUI-p performed OP increased from 96.4% to 99.7%, and proportion of POP-p performed OP increased from 76.5% to 82.8%. 99.9% of OAB-p were performed OP. Charges for SUI-p performed IP were $16,705 higher than those performed OP (p=0.007) and charges for POP-p performed IP were $21,864 higher than those performed OP (p<0.0001). Predictors of SUI-p and POP-p being performed OP included private insurance, fewer co-morbidities, and receiving care at a rural facility or at a center in the Midwest or South. Additionally, SUI-p were more likely to be performed OP for patients < 52 years of age. POP-p were more likely to be performed IP than SUI-p (OR 20.8; 95% CI 20.2 - 21.5), while OAB-p were less likely to be performed IP than SUI-p (OR 0.01; 95% CI 0.01 – 0.02). CONCLUSIONS: An increasing majority of SUI and OAB procedures performed nationwide are performed in OP settings. These procedures performed OP carry less charge than those performed IP and are more likely for younger, healthier patients with private insurance. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e657 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Connie Wang More articles by this author Daniel Schoenfeld More articles by this author Joseph Marte More articles by this author Gregory Joice More articles by this author Expand All Advertisement PDF downloadLoading ...