Outpatient Encounters Research Articles

Healthcare Utilization Among Infants Covered by Medicaid and Newly Diagnosed With Respiratory Syncytial Virus.

Infants covered by Medicaid have higher respiratory syncytial virus (RSV) hospitalization rates than those with commercial insurance, but findings are limited to the inpatient setting. This birth cohort study describes healthcare encounters for RSV across all settings among infants covered by Medicaid and the Children's Health Insurance Program. Medicaid claims for infants born and residing in Arizona (AZ), California (CA), Florida (FL), Michigan (MI), North Carolina (NC), New York (NY), and Texas (TX) were analyzed for first diagnosis of RSV in 2016-2018 using International Classification of Diseases, Tenth Revision codes. Encounters on the day of first diagnosis were examined by setting in 7 states and by setting and race in CA, FL, and NC. A total of 80 945 infants were diagnosed with RSV in 7 states in 2016-2018. The highest encounter rates for first RSV diagnosis were in the emergency department (ED) in 5 states (11.0-33.4 per 1000 in AZ, CA, FL, MI, and NY) and outpatient setting in 2 states (54.8 and 68.5 per 1000 in TX and NC). Significantly higher outpatient encounter rates were found in CA and NC for White infants compared to non-White infants. In NC, ED encounter rates were significantly higher for non-White infants than White infants, whereas in CA, the rates were comparable. In these 2 states, hospitalization rates were similar across groups. In FL, compared with White infants, non-White infants had significantly higher encounter rates in each setting on the day of first RSV diagnosis. This is the first study to describe the burden of RSV by setting and race. Medicaid infants who are newly diagnosed with RSV have the highest burden in ED and outpatient settings.

Quality of Outpatient Pediatric Palliative Care Telehealth: A Retrospective Chart Review

ContextStudies suggest the feasibility and acceptability of telehealth in outpatient pediatric palliative care. However, there is a need for data that describes the implementation and quality of telehealth, relying on objective and validated measures. ObjectiveWe sought to compare the provision of pediatric palliative care by delivery method. MethodsWe conducted a retrospective electronic health record review of patients seen by our outpatient palliative care team over a two-year period. Demographic, diagnostic, and health utilization data as well as encounter characteristics were compared between patients seen in person (IP), through telehealth (TH), and both (IP/TH). ResultsThree hundred ninety-four patients were evaluated with 889 outpatient pediatric palliative care encounters. Non-English speaking patients were less likely to receive palliative care through TH, as were patients without active patient portals. Median follow-up time was longer for patients seen through TH or IP/TH. Patients with malignancies were seen more frequently IP while children with neurologic diagnoses, technology dependence, and a higher number of complex chronic conditions were seen more frequently via TH. Health outcomes, end of life quality metrics, and encounter-level quality indicators were similar across care delivery methods. Review of systems, pain, and mood management, and advance care planning happened more frequently IP while goals of care discussions and medical decision-making happened more through TH. ConclusionDespite differences in patients seen and palliative interventions provided in person compared to telehealth, health outcomes, and quality indicators were similar across care delivery methods. These data support the continued practice of telehealth in palliative care and highlight the need for equity in its evolution.

Abstract MP35: Long-Term Trajectories of Self-Rated Health Are Similar Following Incident Diabetic Foot Disease and Acute Myocardial Infarction Among Adults With Diabetes in the Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Incident diabetic foot disease is associated with significant morbidity and mortality. However, data are lacking on long-term patient-reported outcomes. We aimed to evaluate trajectories of self-rated health among adults with diabetes before and after incident foot disease compared to incident acute myocardial infarction (MI), another major diabetes complication. Methods: We conducted a longitudinal analysis of participants in the ARIC Study with diabetes and incident diabetic foot disease (N=749 hospitalizations, N=73 outpatient encounters) or incident MI (N=703). Diagnosis and procedure codes from active hospitalization surveillance and Medicare claims were used to identify events; only MI events were adjudicated. Self-rated health was collected during annual telephone calls and rated from 1 (poor) to 4 (excellent); a score of 0 was assigned to deaths. We used linear regression to examine changes in self-rated health from 1 year pre-event (baseline). Relative effects of index event type over time were estimated by repeated-measures ANOVA. Results: Self-rated health was similar between groups at baseline ( Figure ). Participants with MI had sharper declines from baseline at 1 year post-event than those with diabetic foot disease (-0.93 vs -0.50 points, P<0.01), largely due to higher mortality (29.4% after MI vs 15.9% after diabetic foot disease). Self-rated health stabilized in the outpatient diabetic foot group after 2 years post-event, whereas it continued to decline over 10 years following both MI and inpatient diabetic foot disease ( Figure ). Conclusions: Our findings suggest outpatient diabetic foot disease is primarily associated with a short-term drop in self-rated health, but inpatient diabetic foot disease is associated with long-term declines in self-rated health similar to those experienced after MI. These results reinforce the importance of early diagnosis and treatment of foot disease and of including patient-reported outcomes to measure sequelae of diabetes complications.

Predictors of a Preference for Telemedicine Virtual Visits in Patients Undergoing Cancer Rehabilitation.

The purpose of this retrospective study was to examine the use of virtual visits (telemedicine) at our cancer rehabilitation outpatient clinics from March 2020 to August 2021, when virtual visits became more widely available, and to identify any demographic and clinical variables making patients more likely to favor virtual over in-person visits. There were 3971 outpatient encounters (2020 virtual and 1951 in-person visits from a total of 1638 patients) in our cancer rehabilitation outpatient clinics during this time frame. Significant findings in both the univariate and multivariate analyses were race ( P < 0.001 and P = 0.006, respectively), cancer type ( P < 0.001 for both), and distance to the clinic ( P < 0.001 for both). Our research showed that virtual visits were accepted by patients with cancer, and that younger age (62 compared to 65), non-White race/ethnicity, solid tumor, and shorter distance to the clinic were associated with a preference for virtual over in-person visits.

Sex Differences in Postinjury Health Profiles Among U.S. Military Personnel Following Deployment-Related Concussion.

Background: Women in the U.S. military are now authorized to serve in direct combat occupations. This may increase their risk of combat injuries, such as concussion, in future conflicts. Knowledge of sex differences in health profiles after concussion is paramount for military medical planning efforts. The purpose of this study was to assess sex-related differences in health profiles among U.S. military personnel following deployment-related concussion. Materials and Methods: We conducted a retrospective study of service members who sustained a concussion during combat deployment between 2004 and 2013. Postinjury diagnoses were abstracted from outpatient encounters in electronic health records for 24 months after concussion. We used hierarchical clustering to identify clusters, termed "health profiles," and logistic regression to determine whether sex predicted membership in the health profiles. Results: The study sample included 346 women and 4536 men with deployment-related concussion. Five postinjury health profiles were identified and classified as no morbidity, back pain, tinnitus/memory loss, posttraumatic stress disorder/postconcussion syndrome, and multimorbidity. Women relative to men had higher odds of membership in the back pain (odds ratio [OR] = 1.32; 95% confidence interval [CI] = 1.05-1.67) and multimorbidity profiles (OR = 1.44; 95% CI = 1.03-2.00) and lower odds than men in the tinnitus/memory loss profile (OR = 0.62; 95% CI = 0.42-0.91). Conclusions: Postinjury health profiles among U.S. service members differ by sex following deployment-related concussion, particularly with a higher burden of multimorbidity among women than men, which may require interdisciplinary care. Women also had higher odds of membership in the back pain profile and lower odds in the tinnitus/memory loss profile than men. To prepare for future military operations where women may have greater exposure to combat, continued research elucidating health-related sex differences after deployment-related concussion is imperative.

Development and Validation of Case-Finding Algorithms to Identify Pancreatic Cancer in the Veterans Health Administration.

Survival in pancreatic ductal adenocarcinoma (PDAC) remains poor due to late diagnosis. Electronic Health Records (EHRs) can be used to study this rare disease, but validated algorithms to identify PDAC in the United States EHRs do not currently exist. To develop and validate an algorithm using Veterans Health Administration (VHA) EHR data for the identification of patients with PDAC. We developed two algorithms to identify patients with PDAC in the VHA from 2002 to 2023. The algorithms required diagnosis of exocrine pancreatic cancer in either ≥ 1 or ≥ 2 of the following domains: (i) the VA national cancer registry, (ii) an inpatient encounter, or (iii) an outpatient encounter in an oncology setting. Among individuals identified with ≥ 1 of the above criteria, a random sample of 100 were reviewed by three gastroenterologists to adjudicate PDAC status. We also adjudicated fifty patients not qualifying for either algorithm. These patients died as inpatients and had alkaline phosphatase values within the interquartile range of patients who met ≥ 2 of the above criteria for PDAC. These expert adjudications allowed us to calculate the positive and negative predictive value of the algorithms. Of 10.8 million individuals, 25,533 met ≥ 1 criteria (PPV 83.0%, kappa statistic 0.93) and 13,693 individuals met ≥ 2 criteria (PPV 95.2%, kappa statistic 1.00). The NPV for PDAC was 100%. An algorithm incorporating readily available EHR data elements to identify patients with PDAC achieved excellent PPV and NPV. This algorithm is likely to enable future epidemiologic studies of PDAC.

An extra X chromosome among adult women in the Million Veteran Program: A more benign perspective of trisomy X.

Despite affecting in 1 in every 1000 females, remarkably little is known about trisomy X syndrome (47,XXX), especially among older adults who are undiagnosed. In this study, we aimed to determine the prevalence of 47,XXX among females enrolled in the Million Veterans Program (MVP; mean age 50.2 ± 13.6 years), and compare broad health outcomes between females with 47,XXX and 46,XX matched controls. We identified 61 females with an additional X chromosome, corresponding to a prevalence of 103 per 100,000 females; 27.9% had been clinically diagnosed. Females with 47,XXX had taller stature (+6.1 cm, p < 0.001), greater rate of outpatient encounters (p = 0.026), higher odds of kidney disease (odds ratio [OR] = 12.3; 95% confidence interval [CI] 2.9-51.8), glaucoma (OR = 5.1; 95% CI 1.5-13.9), and congestive heart failure (OR = 5.6; 95% CI 1.4-24.2), and were more likely to be unemployed (p = 0.008) with lower annual income (p = 0.021) when compared with 46,XX controls of the same age and genetic ancestry. However, there were no differences in the rates of other encounter types, Charlson Comorbidity Index, all other medical and psychological diagnoses, military service history or quality of life metrics. In conclusion, in this aging and predominately undiagnosed sample, 47,XXX conferred few differences when compared with matched controls, offering a more reassuring perspective to the trisomy X literature.

Randomized Comparison of Electronic Health Record Alert Types in Eliciting Responses about Prognosis in Gynecologic Oncology Patients.

To compare the ability of different electronic health record alert types to elicit responses from users caring for cancer patients benefiting from goals of care (GOC) conversations. A validated question asking if the user would be surprised by the patient's 6-month mortality was built as an Epic BestPractice Advisory (BPA) alert in three versions-(1) Required on Open chart (pop-up BPA), (2) Required on Close chart (navigator BPA), and (3) Optional Persistent (Storyboard BPA)-randomized using patient medical record number. Meaningful responses were defined as "Yes" or "No," rather than deferral. Data were extracted over 6 months. Alerts appeared for 685 patients during 1,786 outpatient encounters. Measuring encounters where a meaningful response was elicited, rates were highest for Required on Open (94.8% of encounters), compared with Required on Close (90.1%) and Optional Persistent (19.7%) (p < 0.001). Measuring individual alerts to which responses were given, they were most likely meaningful with Optional Persistent (98.3% of responses) and least likely with Required on Open (68.0%) (p < 0.001). Responses of "No," suggesting poor prognosis and prompting GOC, were more likely with Optional Persistent (13.6%) and Required on Open (10.3%) than with Required on Close (7.0%) (p = 0.028). Required alerts had response rates almost five times higher than optional alerts. Timing of alerts affects rates of meaningful responses and possibly the response itself. The alert with the most meaningful responses was also associated with the most interruptions and deferral responses. Considering tradeoffs in these metrics is important in designing clinical decision support to maximize success.

Abstract A001: Tracking the Relationship between Accrual and Comorbidities in Clinical TRrial Enrollment (TRACE)

Abstract Background: Clinical trial accrual disparities are pervasive and multifactorial. Prior research shows differential racial enrollment patterns of cancer patients due to comorbidity-based exclusion criteria (CEC). Uterine cancer (UC) has one of the largest racial disparities in incidence and mortality, yet the impact of CEC on accrual of racial minorities into UC trials is unknown. Objective/Hypothesis: To 1) characterize the presenting comorbidity profile of UC patients, by race and 2) use real-world data to quantify expected effects of common CEC on UC trial accrual. We hypothesize that racial minorities with UC have more comorbidities resulting in higher exclusion from trials than Whites. Method: In this observational, cross-sectional study, we used the Vizient ® Clinical Data Base [permission of Vizient Inc. (all rights reserved)] with 8.5 million inpatient and 130 million outpatient encounter level claims annually. We identified individuals ≥18yo with a UC diagnosis, 2002–2021. Demographic variables and comorbidity diagnoses were identified by ICD9/10 codes and used to construct Charlson, Elixhauser, and National Cancer Institute (NCI) comorbidity indices (CI). Individual comorbidity-based and summary theoretical ineligibility rates were calculated, by race, based on a modified set of CEC (Riner et al, JCO 2022). Ineligibility rates were compared between groups and differences assessed with logistic regression using STATA v.18. Result: We identified 384,093 UC patients. 73% were White, 14% Black, 11% unknown race, and 3% Asian. The majority (61%) were of non-Hispanic ethnicity. On average, Blacks had more comorbidities than Whites, Asians, or those of unknown race [1.3 (SD 2), 0.7 (SD 1.6), 0.6 (SD 1.3), 0.9 (SD 1.6), respectively]. For NCI CI, Blacks had the highest CI score (0.8, SD 1.4) while Asians the lowest (0.4, SD 0.9). Whites and those of unknown race had similar scores (0.5, SD 1.1) (all p-values &amp;lt; 0.001). Individual comorbidity prevalence varied significantly by race. Blacks (12%) with UC were more likely to have renal failure compared to Whites (5%). Asians (14%) and Whites (15%) had similar rates of diabetes while Blacks had the highest (24%). Hypertension was higher in Blacks (50%), followed by Whites (33%) then Asians (28%). In simulation analyses, odds of trial exclusion based on comorbidity status were two times higher in Blacks compared to Whites (OR 2.09, 95% CI 2.05-2.13). Those of unknown race had slightly higher odds (OR 1.04, 95% CI 1.02-1.07) and Asians lower odds (OR 0.89, 95% CI 0.86-0.93) of being ineligible relative to Whites. Conclusion: For UC patients, comorbidity prevalence and CI scores varied by race. This results in significant differences in trial eligibility at baseline before any patient engagement. Quantifying the distribution of comorbidities is critical because it allows us to anticipate, statistically, how the accrual of minorities may be hampered by individual CEC. This in turn can support equity efforts of targeted oversampling and strategic site selection to ensure diverse participants. Citation Format: Ann Oluloro, Mindy Pike, Adrienne Moore, Tiffany Luu, Soledad Jorge, Kemi M. Doll. Tracking the Relationship between Accrual and Comorbidities in Clinical TRrial Enrollment (TRACE) [abstract]. In: Proceedings of the AACR Special Conference on Endometrial Cancer: Transforming Care through Science; 2023 Nov 16-18; Boston, Massachusetts. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(5_Suppl):Abstract nr A001.

Evaluating a conceptual framework for quality assessment of medical interpretation

ObjectiveWe aimed to evaluate a proposed conceptual framework for quality assessment of medical interpretation using actual data from clinical settings. MethodsA mixed methods approach was used. Routine outpatient encounters involving Portuguese-speaking Brazilian patients, Japanese physicians, and hospital-provided and ad hoc interpreters were digitally recorded and transcribed. A questionnaire survey examining participants’ satisfaction was conducted; 111 and 13 encounters by hospital-provided and ad hoc interpreters, respectively, were recorded. Segments of consecutively interpreted utterances were coded as “altered,” whereby the interpreter changed the meaning of the source utterance, or “unaltered (accurate).” Frequency and type of alteration were analyzed. The effect of positive interpretation alterations on physician-patient interactions was qualitatively described. ResultsInterpretation accuracy was significantly higher for hospital-provided interpreters, but was not associated with overall patient satisfaction. Overall physician satisfaction was associated with accurate interpretation, clinically negative altered interpretations, and positive voluntary interventions (p < 0.05). Positive alterations promoted patient, physician, and interpreter interactions, which helped to achieve clinical outcomes. ConclusionA new conceptual framework for quality assessment of medical interpretation was developed for clinical settings. Healthcare provider satisfaction can provide a measure of interpretation alterations. Practice implicationsHealthcare providers can effectively use the conceptual framework to improve medical interpretation and collaboration with healthcare interpreters.

Evaluating drug use patterns among paediatric outpatients in Burundi.

Rational prescribing is key to optimising therapeutic outcomes and avoiding risks associated with irrational use of medicines. Using WHO drug use indicators, this study evaluated drug use patterns among paediatric outpatient encounters at Primary Healthcare Centers (PHCs) in Bujumbura Mairie, Republic of Burundi. Descriptive cross-sectional research assessed paediatric medicine use in 20 PHCs. From 8 February to 7 April 2023, 800 randomly selected paediatric encounters' 2022-year data were retrospectively collected. Data for specific facility indicators were prospectively collected. SPSS 23 was used to analyse data. 800 outpatient child encounters were analysed, 48.4% female and 51.6% male. The mean number of medicines per encounter was 2.4(±0.99). The injection rate was 9.9%. Overall, 78.8% of generics and 85.2% of essential medicines were prescribed. Results show drug prescribing differences between private and government PHCs (p < 0.001). All PHCs studied had no standard treatment guidelines (STGs), while 50% had an essential medicine list (EML) and 85% of key medicines were available. Poor prescribing practices were found indicating the need for interventions to promote good drug use practices. A large study at a national scale is required to provide a more comprehensive understanding of the overall drug use practices.

Impact of Atrial Fibrillation Burden on Health Care Costs and Utilization

BackgroundIntegrating patient-specific cardiac implantable electronic device (CIED)-detected atrial fibrillation (AF) burden with measures of health care cost and utilization allows for an accurate assessment of the AF-related impact on health care use. ObjectivesThe goal of this study was to assess the incremental cost of device-recognized AF vs no AF; compare relative costs of paroxysmal atrial fibrillation (pAF), persistent atrial fibrillation (PeAF), and permanent atrial fibrillation (PermAF) AF; and evaluate rates and sources of health care utilization between cohorts. MethodsUsing the de-identified Optum Clinformatics U.S. claims database (2015-2020) linked with the Medtronic CareLink database, CIED patients were identified who transmitted data ≥6 months postimplantation. Annualized per-patient costs in follow-up were analyzed from insurance claims and adjusted to 2020 U.S. dollars. Costs and rates of health care utilization were compared between patients with no AF and those with device-recognized pAF, PeAF, and PermAF. Analyses were adjusted for geographical region, insurance type, CHA2DS2-VASc score, and implantation year. ResultsOf 21,391 patients (mean age 72.9 ± 10.9 years; 56.3% male) analyzed, 7,798 (36.5%) had device-recognized AF. The incremental annualized increased cost in those with AF was $12,789 ± $161,749 per patient, driven by increased rates of health care encounters, adverse clinical events associated with AF, and AF-specific interventions. Among those with AF, PeAF was associated with the highest cost, driven by increased rates of inpatient and outpatient hospitalization encounters, heart failure hospitalizations, and AF-specific interventions. ConclusionsPresence of device-recognized AF was associated with increased health care cost. Among those with AF, patients with PeAF had the highest health care costs. Mechanisms for cost differentials include both disease-specific consequences and physician-directed interventions.

Police-mental health co-response versus police-as-usual response to behavioral health emergencies: A pragmatic randomized effectiveness trial

BackgroundPeople with mental illness are overrepresented in United States (US) criminal legal systems. In response, alternatives to traditional police response to behavioral health emergencies have become more common, despite limited evidence for their effectiveness. We conducted the first randomized controlled trial of a police-mental health co-response team to determine program effectiveness relative to a police-as-usual response on key outcomes identified by community stakeholders. MethodsBetween January 2020 and March 2021, we randomized behavioral health emergency calls for service in one of six police districts in Indianapolis, Indiana to receive a co-response or police-as-usual response during operational hours between 10 a.m. and 5 p.m. Mondays – Fridays. Eligible calls for service were determined via pre-specified phrases indicating a behavioral health incident over the police dispatch radio. Researchers then communicated random assignment with the co-response team to indicate whether they should respond or withhold. Logistic and negative binomial regression were used to assess group differences in emergency medical services (EMS) events within 12 months of the randomized incident along with jail booking, outpatient encounters, and emergency department visits. FindingsWe randomized 686 calls for service with co-response completed in 264 cases and police-as-usual response in 267 cases. The overall rate of attrition was similar across conditions and the final sample included 211 co-responses and 224 police-as-usual responses. We found no significant differences in any EMS event (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 0.85–1.88, p = .246) or event counts (incidence rate ratio [IRR]: 0.85; 95% CI: 0.52–1.37, p = .504). We also found no differences in secondary outcomes (jail booking, outpatient encounters, and emergency department visits). DiscussionA police-mental health co-response team model was not more effective than traditional police response on key outcomes. Co-response team models, such as the one reported here, may unintentionally foster emergency services utilization among persons with behavioral health needs. Without a functioning national mental health system, communities in the US will continue to struggle to identify solutions to meet the needs of community members with complex behavioral health issues.

Effects of Non-Face-to-Face Chronic Care Management on Service Utilization and Outcomes Among US Medicare Beneficiaries with Diabetes.

Type 2 diabetes mellitus (T2DM) results in heavy economic and disease burdens in Louisiana. The Centers for Medicare and Medicaid Services has reimbursed non-face-to-face chronic care management (NFFCCM) for patients with two or more chronic conditions since 2015. To assess the impacts of NFFCCM on healthcare utilization and health outcomes. This retrospective cohort study included Medicare fee-for-service beneficiaries with T2DM and at least one additional chronic disease between 2014 and 2018. At least one record of NFFCCM Current Procedural Terminology codes. The health outcomes in the study included major adverse cardiovascular events (MACE), all-cause mortality, and heart failure. The monthly service utilization and continuity of care index for primary care were also included. The propensity score method was used to balance the baseline differences between the two groups. Weighted multivariate regression models were developed using propensity score weights to assess the impacts of NFFCCM on outcomes. During the 5years of study period, 8415 patients among the 118,643 Medicare beneficiaries received at least one NFFCCM. Patients receiving any NFFCCM had reduced healthcare utilization compared with patients not receiving NFFCCM, including 0.012 (95% CI - 0.014 to - 0.011; p < 0.001) fewer monthly hospital admissions, 0.017 (95% CI - 0.019 to - 0.016; p < 0.001) fewer monthly ED visits, and 0.399 (95% CI 0.375 to 0.423; p < 0.001) more monthly outpatient encounters. Patients receiving NFFCCM services had lower MACE event rates of 7.4% (95% CI 7.1 to 7.8%; p < 0.001), all-cause mortality rate of 7.8% (95% CI 7.4 to 8.1%; p < 0.001), and heart failure rate of 0.3% (95% CI 0.2 to 0.5%; p < 0.001), respectively. These findings suggest that reimbursement for NFFCCM was associated with the shifting high-cost utilization to lower-cost primary health care settings among patients with diabetes in Louisiana.

Relationship between facility number of clinicians and prescribing intensity of psychotropic medications, opioids, and antibiotics in ambulatory practice

BackgroundPromoting appropriate pharmacotherapy requires understanding the factors that influence how clinicians prescribe medications. While prior work has focused on patient and clinician factors, features of the organizational setting have received less attention, though identifying sources of variation in prescribing may help identify opportunities to improve patient safety and outcomes.ObjectiveTo evaluate the relationship between the number of clinicians who prescribe medications in a facility and facility prescribing intensity of six individual medication classes by clinician specialty: benzodiazepines, antipsychotics, antiepileptics, and antidepressants by psychiatrists and antibiotics, opioids, antiepileptics, and antidepressants by primary care clinicians (PCPs).DesignWe used 2017 Veterans Health Administration (VHA) administrative data.SubjectsWe included patient-clinician dyads of older patients (> 55 years) with an outpatient encounter with a clinician in 2017. Patient-clinician data from 140 VHA facilities were included (n = 13,347,658). Analysis was repeated for years 2014 to 2016.Main measuresFor each medication, facility prescribing intensity measures were calculated as clinician prescribing intensity averaged over all clinicians at each facility. Clinician prescribing intensity measures included percentage of each clinician’s patients prescribed the medication and mean number of days supply per patient among all patients of each clinician.Key resultsAs the number of prescribing clinicians in a facility increased, the intensity of prescribing decreased. Every increase of 10 facility clinicians was associated with a significant decline in prescribing intensity for both specialties for different medication classes: for psychiatrists, declines ranged from 6 to 11%, and for PCPs, from 2 to 3%. The pattern of more clinicians less prescribing was significant across all years.ConclusionFuture work should explore the mechanisms that link the number of facility clinicians with prescribing intensity for benzodiazepines, antipsychotics, antiepileptics, antidepressants, antibiotics, and opioids. Facilities with fewer clinicians may need additional resources to avoid unwanted prescribing of potentially harmful or unnecessary medications.

Growing Concern About Unsheltered Homelessness Among Veterans: Clinical Characteristics and Engagement in Health Care Services.

Veteran homelessness has declined in the past decade, but the proportion of unsheltered homeless veterans has increased. We identified characteristics of unsheltered homelessness in a large contemporary veteran cohort and examined outpatient and inpatient encounters before and after intake to US Department of Veterans Affairs (VA) homeless programs. National data from the Homeless Operations Management Evaluation System (HOMES) database and the Corporate Data Warehouse were analyzed on 191 204 veterans experiencing housing instability from January 2018 through December 2021. We used hierarchical multivariate logistic regressions to model associations between sheltered status and veteran correlates. Repeated-measures analysis of variance assessed changes in care utilization after intake in homeless programs. Age <50 years (odds ratio [OR] = 1.3; 95% CI, 1.2-1.4), Hispanic ethnicity (OR = 1.2; 95% CI, 1.1-1.3), some college education (OR = 1.1; 95% CI, 1.0-1.1), and a bachelor's degree (OR = 1.2; 95% CI, 1.1-1.2) were associated with veteran unsheltered homelessness. Unsheltered veterans were more likely to have a VA service-connected disability (OR = 1.4; 95% CI, 1.4-1.5), military sexual trauma (OR = 1.1; 95% CI, 1.0-1.1), and/or combat exposure (OR = 1.1; 95% CI, 1.0-1.1). Unsheltered and sheltered homeless veterans had an increase in outpatient encounters and a decrease in inpatient care after intake to the VA homeless program. Contemporary unsheltered homeless veterans are younger and Hispanic with some college education. Innovative public health approaches that better engage and reduce barriers to entry need to be tested for a diverse unsheltered homeless population.

(361) National Trends of Male Urethroplasty Procedures: 2016-2019

Abstract Introduction Urethroplasty remains a valuable surgical option in the management of urethral stricture disease. However, current understanding of the patient- and hospital-level factors associated with inpatient versus (vs.) outpatient male urethroplasty is limited on a national scale. Objective We therefore sought to evaluate contemporary national trends of urethroplasty procedures among men. Methods We performed a retrospective review from 2016 to 2019 of urethroplasty procedures in men utilizing both the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample – the largest publicly available all-payer inpatient and ambulatory databases in the United States. Non-endoscopic urethroplasty procedures were identified by Current Procedural Terminology and International Classification of Diseases (10th Revision) Procedure Coding System codes. Utilizing both inpatient and outpatient encounters, we performed stratified cluster sampling to create weighted national estimates. The primary outcome was the rate of urethroplasty performed in inpatient and outpatient encounters over time. Multivariable logistic regression was used to evaluate patient- and hospital-level factors associated with inpatient urethroplasty. Results From 2016 to 2019, there were 28,532 weighted urethroplasty procedures analyzed (37% inpatient vs. 63% outpatient). Over the study period, there was a 27% increase in the total number of annual procedures (n=6270 to n=7980), and the proportion performed outpatient increased from 60% to 68% [Figure]. Mean total charge for inpatient urethroplasty encounters was $84,267 vs. $30,997 outpatient (p&amp;lt;0.0001). Predictors of inpatient urethroplasty included greater Elixhauser Comorbidity Index, use of buccal mucosal graft, non-private insurance status, and Western hospital region (vs. Northeast) (p&amp;lt;0.05) [Table]. Outpatient urethroplasty was associated with higher median income by Zip Code (vs. lowest quartile of median income), Southern hospital region (vs. Northeast), rural or urban non-teaching hospital (vs. urban teaching hospital), and higher urethroplasty case volume hospitals (vs. lowest case volume hospitals) (p&amp;lt;0.05). Conclusions An increasing proportion of urethroplasty procedures nationwide appears to be performed on an outpatient basis. Outpatient procedures have lower hospital charges than inpatient encounters – and are associated with higher volume hospitals, not using buccal mucosal graft, private insurance, and less comorbid patients who reside in areas of higher median income. Further investigation is warranted to assess how these factors may affect surgical outcomes. Disclosure No.

(214) National Trends of Inpatient vs. Outpatient Male Benign Prostate Hyperplasia Procedures: 2016-2019

Abstract Introduction Benign prostatic hyperplasia (BPH) is a common condition among aging men, causing urinary symptoms and impacting quality of life. Understanding the trends in BPH treatment procedures is crucial for optimizing patient care. Evaluating the utilization of different treatments, the setting of procedures (inpatient vs. outpatient), and associated costs can provide valuable insights. Identifying patient- and hospital-level factors associated with inpatient treatments can help identify disparities in access to care. Assessing the financial implications of care settings can optimize resource allocation. This research aims to contribute to knowledge by providing comprehensive insights into BPH treatment patterns, patient demographics, and healthcare costs for informed decision-making and improved patient outcomes. Objective To evaluate contemporary national trends of BPH treatment procedures among men. Methods An analysis of BPH treatment procedures performed from 2016-2019 was conducted utilizing both the National Inpatient Sample (NIS) and the Nationwide Ambulatory Surgery Sample (NASS). BPH treatment procedures were identified by Current Procedural Terminology (CPT) and International Classification of Diseases (10th Revision) Procedure Coding System (ICD-10-PCS) codes. Stratified cluster sampling was used to create weighted national estimates. The primary outcome was the rate of BPH treatments procedures performed in inpatient and outpatient encounters over time. Multivariable logistic regression was used to evaluate patient- and hospital-level factors associated with inpatient BPH treatments. Results A total of 811,111 weighted BPH treatment procedures analyzed showed that 45% of procedures were performed inpatient, with the remaining 55% performed outpatient over the course of 2016-2019 (Figure 1). Regional analysis revealed a majority of procedures were performed in the South at 36% and about 40% inpatient and outpatient, respectively (Table 1). The proportion of BPH procedures performed outpatient remained stable at 55% from 2016-2019 (Figure 1). The average age of a treated patient was similar between 66 inpatient and 70 outpatient. Multivariable logistic regression analysis showed an Elixhauser Comorbidity Index greater than 0 as a predictor of inpatient BPH treatment (Table 2). Medicare was the primary payer for both inpatient and outpatient settings at 51% and 60% respectively. Mean total charge for inpatient BPH encounters was $70,061 vs. $22,716 outpatient. Conclusions A sizable majority of BPH treatment procedures nationwide appear to be performed in an outpatient setting. Outpatient procedures have a lower total charge compared to inpatient care, which appears to be a contributing factor. Most inpatient procedures are more likely to be performed on patients. Further investigation is warranted to assess how these factors may affect surgical outcomes. Disclosure No.

(360) National Trends in Male Artificial Urinary Sphincters: 2016-2019

Abstract Introduction The artificial urinary sphincter (AUS) remains the gold standard for male stress urinary incontinence. However, current understanding of which patient- and facility-level characteristics that are associated with inpatient versus (vs.) outpatient AUS procedures is limited on a national scale. Objective We therefore sought to evaluate contemporary national trends of AUS procedures. Methods We performed a retrospective review of male AUS procedures using the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample – the largest publicly available all-payer inpatient and ambulatory healthcare databases in the United States – from 2016 to 2019. AUS insertion, repair, replacement, and removal were identified by Current Procedural Terminology and International Classification of Diseases (10th Revision) Procedure Coding System codes. Our unit of analysis was inpatient or outpatient encounters, and we performed stratified cluster sampling to create weighted national estimates. The primary outcome was the proportion of AUS procedures performed in the inpatient and outpatient settings over time. We performed multivariable logistic regression to evaluate factors associated with an inpatient encounter. Results There were 21,916 weighted AUS procedures analyzed from 2016 to 2019 (6% inpatient vs. 94% outpatient). There was a 15% increase in total number of annual surgeries (n=5066 to n=5843), and the proportion performed outpatient increased from 92% to 95% over the study period [Figure]. Mean total charge for inpatient AUS surgery was $92,045 vs. $72,887 for outpatient (p&amp;lt;0.05). Inpatient AUS surgery was associated with greater Elixhauser Comorbidity Index, non-private insurance, and Western hospital region (vs. Northeast) (p&amp;lt;0.05) [Table]. Predictors of outpatient AUS procedures included older age, 3rd quartile of median income by Zip Code (vs. 1st quartile), and Midwest/Southern hospital region (vs. Northeast) (p&amp;lt;0.05). Conclusions With an increasing rate of AUS procedures in the United States, the majority of these procedures continue to be performed on an outpatient basis. Outpatient procedures have lower hospital charges compared to inpatient encounters, and outpatient AUS is associated with private insurance in older patients with fewer comorbidities. Hospital geographic region appears to affect encounter type, and further work may elucidate how these factors affect patient outcomes nationally. Disclosure No.

(091) The Association Between Hypogonadism, Frailty, and Postoperative Outcomes Among Men Undergoing Radical Cystectomy

Abstract Introduction Hypogonadism is associated with frailty, lower health-related quality of life, decreased muscle mass, and premature mortality, which may predispose patients to poor postoperative outcomes. However, the prevalence and importance of hypogonadism and frailty among men undergoing radical cystectomy (RC) remains unknown. Objective We aimed to determine the prevalence of hypogonadism in men undergoing RC and whether hypogonadism and frailty are associated with adverse postoperative outcomes in this population. Methods We utilized the IBM Marketscan database, which contains information on inpatient admissions, outpatient encounters, and outpatient prescriptions from Commercial and Medicare plans. Inpatient admissions were used to identify men who underwent RC between 2012-2021. Frailty was coded using diagnosis codes available in the year prior to RC and categorized as low-, intermediate-, or high-risk using published Hospital Frailty Risk Score (HFRS) ranges. Patients were considered to have hypogonadism if they had a diagnosis in the 5 years prior to RC. Demographics and surgical outcomes including length of stay (LOS), complications, and rate of 90-day ED visits and 90-day inpatient readmissions were collected. Sub-group analysis was also performed among men with hypogonadism to determine the effect of testosterone replacement therapy (TRT) on clinical outcomes. Differences in baseline characteristics between hypogonadism and control cohorts were assessed via Kruskal Wallis and Chi-squared tests, as appropriate. Multivariable Cox proportional hazards models were used to assess the association between hypogonadism and frailty and the rate of ED visits or inpatient readmissions following RC. To focus on post-RC events, patients without an ED visit or readmission were censored at 90 days. Significance was determined using p&amp;lt;0.05. Results Among 3,729 men who underwent RC, 228 (6.1%) had a diagnosis of hypogonadism within 5 years prior to RC. Overall, 564 (15.1%) men were categorized as low-risk frailty, 2,216 (59.4%) were intermediate-risk frailty, and 949 (25.4%) were high-risk frailty. Men with hypogonadism were significantly more frail compared to men without hypogonadism (p=0.001). There was no significant difference in age, LOS, postoperative complications, ED visits, or rate of inpatient readmissions between cohorts (p&amp;gt;0.05). However, high-risk frailty was independently associated with an increased risk of ED visit (HR 1.29, 95% CI [1.09-1.52], p=0.003) and inpatient readmissions (HR 1.55, 95% CI [1.27-1.89], p&amp;lt;0.001) following RC. On sub-group analysis of men with hypogonadism, 48 (21.1%) had a prescription for TRT within 5 years prior to RC. There was no difference in demographics, frailty, LOS, complications, or 90-day ED visits or 90-day inpatient readmissions between groups. Among men with hypogonadism, high-risk frailty was also associated with increased risk of inpatient readmission (HR 1.45, 95% CI [1.03-2.04], p=0.03). Conclusions Hypogonadism was associated with worse preoperative frailty, but was not independently associated with poor postoperative outcomes among men undergoing RC. However, high-risk frailty was associated with increased odds of postoperative ED visits and inpatient readmission. While prospective data is required to validate our results, these findings suggest that both hypogonadism and preoperative frailty should be evaluated prior to undergoing RC. Disclosure No.