Outpatient Health Care Encounters Research Articles

#1241 Healthcare resource utilisation in adults with chronic kidney disease by KDIGO categorisation in England: 2010-2019

Abstract Background and Aims Chronic kidney disease (CKD) is associated with high clinical burden for patients and substantial economic costs for healthcare systems. Detailed estimates of healthcare resource utilization (HCRU) for patients with CKD in the UK are limited, particularly by stage of CKD. This study assessed outpatient and non-elective inpatient HCRU by stage of CKD in England. Method This non-interventional study utilised data from primary care electronic health records from Clinical Practice Research Datalink (CPRD) AURUM and Hospital Episode Statistics (HES) admitted patient care (APC). Patients aged ≥18 years registered in CPRD with eligible linkage to HES between January 1, 2010 and December 31, 2019 with 2+ eGFR measurement during the period were identified. CKD was defined by eGFR <60 ml/min/1.73 m2 and/or presence of a uACR measurement ≥3 mg/mmol, both confirmed by a second measurement 90-365 days later. Start of follow-up (index) was set to the earliest date during the study period that CKD was confirmed. Follow-up for HCRU ended at earliest of death, administrative censoring, or 31st December 2019. Patients with end-stage kidney disease (eGFR <9 ml/min/1.73 m2) at index were excluded. Number of HCRU events for each HCRU category was estimated as rates per 1,000 person years (PY) for each calendar year based on cumulative number of events. Event rates were calculated as number of outcomes/total time at risk. Confidence intervals (95%) were calculated assuming a Poisson distribution. Age- and sex-adjusted rates were calculated to compare rates across CKD stages. Results Of 6.1 million adult patients meeting study inclusion criteria, 743,945 adults (12.2%) with CKD were identified. Mean age (SD) was 76.1 (11.5) years, 55.2% were female, and 89.8% White, contributing a total of 3,055,600 years of follow-up. Most (60.9%) patients had stage 3a CKD (eGFR 45-<59 ml/min/1.73 m2). Among patients with uACR measurements (44.4%), 48.0% were A1 (<3 mg/mmol), 44.4% A2 (3-30 mg/mmol), and 7.6% A3 (>30 mg/mmol). Overall, per 1000 PY, there were 24,763 primary care visits, 475 non-elective all-cause hospitalisations, 4,950 attended (722 unattended) outpatient visits, including 308 (43 unattended) outpatient nephrology visits and 368.1 attended (61.2 unattended) cardiology visits. For all HCRU categories, greater KDIGO risk category at index was associated with higher HCRU. For example, after age and sex adjustment, patients with CKD stage 3b had a mean of 0.53/PY non-elective all-cause hospitalisations compared to 0.77/PY for patients with CKD stage 4. Additionally, a mean of 5.18 outpatient visits per PY was observed for patients with CKD stage 3b, of which 0.91 were nephrology outpatient visits compared to 8.39 outpatient visits per PY for stage 4, of which 2.65 were nephrology outpatient visits. Generally, both lower eGFR and higher uACR were individually associated with higher HCRU. Conclusion This study demonstrates high HCRU for patients with CKD, with increasing rates of HCRU with lower kidney function and greater kidney damage. Patients with more advanced CKD contribute at a disproportionally higher rate of outpatient healthcare encounters and non-elective hospitalisations. Efforts to prevent the development and progression of CKD and improving clinical outcomes will reduce frequency and cost of HCRU.

Follow-Up Care After Maltreatment: Sociodemographic Associations With Timeliness in a Southern State.

Children who experience maltreatment are at elevated risk of developing mental health difficulties. Even so, they often do not receive timely, evidenced-based mental health treatment, which may exacerbate the risk of poor outcomes. This study aims to describe the receipt of timely follow-up care after maltreatment in a southern state with known treatment shortages and aims to identify factors associated with timely follow-up care. We utilized a retrospective cohort design using 2014 Mississippi Medicaid administrative claims data for youth 0-18years. Prevalence estimates and associations with definite and probable maltreatment (based on recorded age/injury combinations) during inpatient and outpatient healthcare encounters were evaluated. Rates of 30-day maltreatment follow-up with any medical or behavioral health provider were also assessed. Prevalence estimates of definite and probable maltreatment in the eligible study population (N = 324,752) were 0.53% and 3.8%, respectively. Only one-third of identified children received 30-day follow-up. Black and older children as well as children diagnosed with anxiety or depression were more likely to receive 30-day follow-up than younger children, white children, and children without anxiety or depression. Low rates of timely follow-up indicate the need for intentional workflow practices to increase the likelihood of follow-up.

144. Prophylactic proximal junctional measures improves cost efficacy of adult spinal deformity surgery, with optimal cost utility seen in those with concurrent optimal realignment

144. Prophylactic proximal junctional measures improves cost efficacy of adult spinal deformity surgery, with optimal cost utility seen in those with concurrent optimal realignment

211. Assessing the economic benefit of robotic and navigational assistance in surgical treatment of L4-L5 spondylolisthesis: is higher upfront equipment cost worth the operative and safety benefits?

<h3>BACKGROUND CONTEXT</h3> The use of robotic or navigational guidance has seen tremendous growth in recent years in minimally invasive spine surgery (MISS) due to its ability to reduce operative time, increase patient safety, and aid in surgical accessibility, especially in high incidence pathologies. However, there remain considerable gaps in the literature in regards to the cost-effectiveness of robotic or navigational guidance in the surgical treatment of L4-L5 spondylolisthesis. <h3>PURPOSE</h3> To assess differences in patient outcomes and relative cost effectiveness in L4-L5 spondylolisthesis patients treated using robotic or navigational guidance in MISS procedures. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of prospective MISS database. <h3>PATIENT SAMPLE</h3> A total of 524 MISS patients. <h3>OUTCOME MEASURES</h3> HRQLs, complications, surgical factors. <h3>METHODS</h3> MISS patients with preoperative diagnoses of L4-L5 spondylolisthesis and baseline (BL) and 2-year (2Y) postoperative radiographic/HRQL data were included. Patients were split between those operated on using robotic or navigational guidance (Robotic+) or not (Robotic-). Means comparison analysis assessed differences in radiographic and clinical outcomes at BL, 1Y and 2Y postoperatively. Costs were calculated using the PearlDiver database through estimates from Medicare payscales for services within a 30-day window, including estimates regarding costs of postoperative complications, outpatient healthcare encounters, revisions and medical related readmissions. Quality-adjusted life years (QALYs) was calculated using NDI mapped to SF6D using validated methodology and utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). <h3>RESULTS</h3> Eighty-eight patients (54.40±12.49 years, 40% female, 30.93±6.52 kg/m², mean CCI: 2.23±1.55) with L4-5 spondylolisthesis were included. At baseline, patients were comparable in age, gender, BMI and CCI (all p>.05). Similarly, patients did not differ significantly in baseline regional nor global radiographic deformity (all p>.05). Perioperatively, Robotic+ patients were significantly less likely to undergo corpectomy (p=.006), and also demonstrated significantly lower EBL (p=.013) and operative time (p=.009). Economic analysis revealed broad cost savings for Robotic+ patients. Specifically, Robotic+ patients demonstrated increased utility gained per QALYs at 1Y (p=.028), as well as Life Expectancy QALYs (p=.002). Furthermore, Robotic+ patients were significantly more likely to demonstrate increased QALYs gained by 2Y (p=.029). Conversely, overall cost per QALY by 2Y was significantly higher for Robotic- patients, which resulted in an approximately 6.5x greater cost per QALY for such patients (76,848 vs 11,839 USD). Overall, Robotic+ patients demonstrated significantly higher cost-effectiveness by 2Y (p<.001). <h3>CONCLUSIONS</h3> Corrective procedures for the treatment of L4-L5 spondylolisthesis and other common spinal pathologies has seen significant growth in the uptake of novel technologies such as robotic or navigational assistance. Though robotic and navigational assistance systems have a significantly higher upfront cost compared to existing techniques, our findings demonstrate reductions in intraoperative invasiveness and OR time pay great dividends in demonstrating the 2Y cost-effectiveness of such novel technologies in minimally-invasive adult spinal deformity surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

P102. Determining the impact of proximal junctional kyphosis on cost utility in adult spinal deformity patients

<h3>BACKGROUND CONTEXT</h3> With health care costs on the rise, hospitals have increasingly focused on providing economically efficient medical services. Adult spinal deformity surgery remains an expensive medical intervention with high risk for complications and revisions, especially following mechanical failure in the context of proximal junctional kyphosis (PJK). We sought to evaluate the impact of PJK on associated expenditures following an index surgery for ASD. <h3>PURPOSE</h3> To evaluate the effect of proximal junctional kyphosis on the cost effectiveness of corrective adult deformity surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study of a prospective single-center database of ASD patients. <h3>PATIENT SAMPLE</h3> A total of 147 Adult Spinal Deformity Patients. <h3>OUTCOME MEASURES</h3> Complications, HRQLs (Oswentry Disability Index [ODI]), Quality adjusted life years (QALY). <h3>METHODS</h3> Adult Spinal deformity patients with 2-year HRQL follow-up were included. Utility data was calculated using published conversion methods to convert ODI to SF-6D. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database incorporating complications and comorbidities classified according to CMS standard definitions. Reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for all services rendered within a 30-day window, including estimates regarding costs of postoperative complications, outpatient health care encounters, reoperations and revisions. After accounting for all postoperative events, including mortality, cost per QALY by 2Y was calculated for revisions that occurred due to proximal junctional kyphosis. <h3>RESULTS</h3> A total of 147 adult spinal deformity patients met inclusion criteria (55.22years, 54% Female). At baseline, patients presented radiographically as: Pelvic Tilt (23.66±11.7), Pelvic Incidence- Lumbar Lordosis (-2.9±12.6), Sagittal Vertical Axis (60.5±76.8), T1 Pelvic Angle (22.6±14.3). Surgical details: EBL of 1823 mL, operative time of 327 min, with .4% undergoing an anterior approach, 90.2% posterior-only approach, and 9.3% combined approach. Overall, 54.3% of patients developed PJK within 2 years postoperatively, with 22% undergoing reoperation for PJK. Average cost of revision surgery due to PJK was $93,688 ± $21,467. The cost for PJK patients, including the cost associated with their revision surgery, was higher ($103,760 vs $71,000). Baseline ODI (39 vs 32) and 2Y ODI (39 vs 27) were higher for PJK patients, however, PJK patients did improve to a greater degree (-12 vs -10). The overall cost per QALY by 2Y was higher for PJK patients ($116,170 vs $95,347). <h3>CONCLUSIONS</h3> Patients that developed PJK had an almost $30,000 higher initial cost at 2 years. When looking at the cost per quality adjusted life years by 2Y, PJK resulted in slightly more than $20,000 in cost. These findings suggest prophylactic measures to mitigate PJK may improve the cost utility of adult spinal deformity surgery and can help policy efforts for adequate resource allocation for these complex patients. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

93. Cost utility analysis of a combined approach for surgical correction of adult spinal deformity

BACKGROUND CONTEXT With the increasing emphasis on value-based outcomes in health care, there has been an increased focus on the cost of surgical intervention in patients with adult spinal deformity (ASD). However, there is a paucity of literature on the economic impact of a surgeon's surgical approach for corrective ASD surgery. PURPOSE To investigate the cost-utility associated with surgical approach. STUDY DESIGN/SETTING Retrospective cohort study of a prospective multicenter ASD database. PATIENT SAMPLE This study included 208 ASD patients. OUTCOME MEASURES Oswestry Disability Index (ODI), SF-6D, cost per quality adjusted life years (QALY). METHODS ASD patients with no previous history of fusions, complete radiographic, and HRQL data at baseline and 2 years were included. Patients were propensity score matched for age, CCI, levels fused, frailty, SVA, PI-LL and osteotomies. Means comparison tests and ANOVA chi-squared analyses assessed differences in baseline demographic and clinical data between cohorts. Utility data were calculated using ODI converted to SF-6D using published conversion methods. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database incorporating complications, comorbidities (CC), major complications, and comorbidities (MCC) were assessed according to CMS.gov manual definitions. Two-year reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for all services rendered within a 30-day window, including estimates regarding costs of postoperative complications, outpatient health care encounters, revisions and medical related readmissions. After accounting for CC, MCC, length of stay (LOS), revisions, and death, cost per QALY at 2 years and life expectancy were calculated for surgical approach. RESULTS A total of 208 PSM ASD patients were included (62.2yrs, 84% F, 26.9 kg/m2). Patients undergoing a combined approach had a longer LOS (6.55 vs 8.15), greater operative time, and experienced significantly greater blood loss (all p 0.05). Despite initial higher costs of a combined approach, the average cost of ASD surgery at 2 years follow-up for posterior-only approach was greater compared to a combined approach ($72,749 vs $65,073). Furthermore, the cost per QALY was higher for posterior-only patients at 2 years compared to patients undergoing a combined approach ($363,910 vs $333,981). If utility gained is sustained to life expectancy, the cost per QALY was $54,027 for posterior-only and $49,584 for combined. CONCLUSIONS In a matched cohort of adult spinal deformity patients, a combined approach trended toward a lower average cost of surgery at 2 years, lower cost per QALY, significantly lower rates of operative complications and revisions. Although improvement after surgical intervention was similar between the two approaches, cost per QALY of posterior-only approach was slightly greater primarily driven by increased operative complications and rates of revisions. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

148. Cost utility of revision surgery in cervical deformity patients with distal junctional kyphosis

BACKGROUND CONTEXT With the rise of health care costs and a focus on value-based outcomes, hospitals have become more cognizant on cost of revisions and complications. However, literature on the effect of distal junctional kyphosis in driving up health care costs is scarce. PURPOSE To evaluate the effect of distal junctional kyphosis on the cost effectiveness of corrective cervical deformity surgery. STUDY DESIGN/SETTING Retrospective review of a single surgeon database. PATIENT SAMPLE This study included 123 cervical deformity patients. OUTCOME MEASURES Cost per QALY. METHODS Cervical deformity patients with minimum 1-year HRQL follow-up were included. Means comparison tests assessed differences in baseline demographic and clinical data. Utility data was calculated using published conversion methods to convert NDI to SF-6D. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs was calculated using the PearlDiver database incorporating complications, comorbidities (CC), major complications, and comorbidities (MCC) were assessed according to CMS.gov manual definitions. Reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for all services rendered within a 30-day window, including estimates regarding costs of postoperative complications, outpatient health care encounters, revisions and medical-related readmissions. After accounting for CC, MCC, length of stay (LOS) and death, cost per QALY at 2Y was calculated for revisions due to distal junctional kyphosis. RESULTS A total of 123 cervical deformity patients met inclusion criteria (57.22yrs, 54%F, 29.0kg/m2). At baseline, patients presented radiographically as: PT (16.9±9.7), PI (54.7±11.4), PI-LL (-2.9±12.6), SVA (80.5±49.8), cSVA (28.4±20.6), TS-CL (26.6±14.4). Surgical details: EBL of 708 mL, operative time of 438.6 min, with 29.51% undergoing an anterior approach, 50.82% posterior-only approach, and 19.67% combined approach. Overall, 7.9% of patients developed DJK within two years postoperatively. Average cost of revision surgery due to DJK within 2years of index surgery was $50,736 ± 31,467. Patients that developed DJK within 2years of index surgery trended toward having a greater baseline NDI (62.8 vs 55.47, p>0.05) and showed less improvement in NDI at 2 years (4 vs 16.6). Overall, cost per QALY was higher for patients developing DJK at 2 years ($28,483 vs $20,989). CONCLUSIONS Cervical deformity revisions due to distal junctional kyphosis had a cost per QALY of $28,483. Efforts to limit postoperative DJK after surgical intervention can further limit additional costs associated with revisions and complications. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Characteristics of Adults With Congenital Heart Defects in the United States

BackgroundIn the United States, >1 million adults are living with congenital heart defects (CHDs), but gaps exist in understanding the health care needs of this growing population. ObjectivesThis study assessed the demographics, comorbidities, and health care use of adults ages 20 to 64 years with CHDs. MethodsAdults with International Classification of Disease-9th Revision-Clinical Modification CHD-coded health care encounters between January 1, 2008 (January 1, 2009 for Massachusetts) and December 31, 2010 were identified from multiple data sources at 3 U.S. sites: Emory University (EU) in Atlanta, Georgia (5 counties), Massachusetts Department of Public Health (statewide), and New York State Department of Health (11 counties). Demographics, insurance type, comorbidities, and encounter data were collected. CHDs were categorized as severe or not severe, excluding cases with isolated atrial septal defect and/or patent foramen ovale. ResultsCHD severity and comorbidities varied across sites, with up to 20% of adults having severe CHD and >50% having ≥1 additional cardiovascular comorbidity. Most adults had ≥1 outpatient encounters (80% EU, 90% Massachusetts, and 53% New York). Insurance type differed across sites, with Massachusetts having a large proportion of Medicaid (75%) and EU and New York having large proportions of private insurance (44% EU, 67% New York). Estimated proportions of adults with CHD-coded health care encounters varied greatly by location, with 1.2 (EU), 10 (Massachusetts), and 0.6 (New York) per 1,000 adults based on 2010 census data. ConclusionsThis was the first surveillance effort of adults with CHD-coded inpatient and outpatient health care encounters in 3 U.S. geographic locations using both administrative and clinical data sources. This information will provide a clearer understanding of health care use in this growing population.

Can Hearing Aids Delay Time to Diagnosis of Dementia, Depression, or Falls in Older Adults?

To examine the association between hearing aids (HAs) and time to diagnosis of Alzheimer disease (AD) or dementia, anxiety or depression, and injurious falls among adults, aged 66 years and older, within 3 years of hearing loss (HL) diagnosis. Retrospective cohort study. We used 2008 to 2016 national longitudinal claims data (based on office visit, inpatient, or outpatient healthcare encounters) from a large private payer. We used Kaplan-Meier curves to examine unadjusted disease-free survival and crude and adjusted Cox regression models to examine associations between HAs and time to diagnosis of three age-related/HL-associated conditions within 3 years of HL diagnosis. All models were adjusted for age, sex, race/ethnicity, census divisions, and prior diagnosis of cardiovascular conditions, hypertension, hypercholesterolemia, obesity, and diabetes. The participants included 114 862 adults, aged 66 years and older, diagnosed with HL. Diagnosis of (1) AD or dementia; (2) depression or anxiety; and (3) injurious falls. Use of HAs. Large sex and racial/ethnic differences exist in HA use. Approximately 11.3% of women vs 13.3% of men used HAs (95% confidence interval [CI] difference = -0.024 to -0.016). Approximately 13.6% of whites (95% CI = 0.13-0.14) vs 9.8% of blacks (95% CI = 0.09-0.11) and 6.5% of Hispanics (95% CI = 0.06-0.07) used HAs. The risk-adjusted hazard ratios of being diagnosed with AD/dementia, anxiety/depression, and injurious falls within 3 years after HL diagnosis, for those who used HAs vs those who did not, were 0.82 (95% CI = 0.76-0.89), 0.89 (95% CI = 0.86-0.93), and 0.87 (95% CI = 0.80-0.95), respectively. Use of HAs is associated with delayed diagnosis of AD, dementia, depression, anxiety, and injurious falls among older adults with HL. Although we have shown an association between use of HAs and reduced risk of physical and mental decline, randomized trials are needed to determine whether, and to what extent, the relationship is causal. J Am Geriatr Soc 67:2362-2369, 2019.

Low Rates of Dermatologic Care and Skin Cancer Screening Among Inflammatory Bowel Disease Patients.

Dermatologic manifestations of inflammatory bowel disease (IBD) are common, and certain IBD medications increase the risk of skin cancer. To define the rates of care and factors associated with dermatologic utilization with a focus on skin cancer screening. We utilized a prospective, natural history IBD research registry to evaluate all outpatient healthcare encounters from 2010 to 2016. Gastrointestinal, dermatologic and primary care visits per individual were identified. We calculated the proportion of patients obtaining care, categorized primary indications for dermatologic visits, determined the incidence of melanoma and non-melanoma skin cancers, and used logistic regression to determine factors associated with dermatology utilization. Of the 2127 IBD patients included, 452 (21.3%) utilized dermatology over the study period, and 55 (2.6%) had a total body skin examination at least once. The 452 patients incurred 1633 dermatology clinic visits, 278 dermatologic procedures, and 1108 dermatology telephone encounters. The most frequent indication was contact dermatitis or dermatitis. Factors associated with dermatology use were family history of skin cancer, employment, systemic steroids, longer disease duration, emergency room use, and the number of IBD-related clinic visits. Between 8.3 and 11% of IBD patients recommended for skin cancer screening visited dermatology each year, and the resulting incidence of non-melanoma skin cancer was 35.4/10,000 [95% CI 23.3-51.5] and melanoma was 6.56/10,000 [95% CI 2.1-15.3]. Less than one in ten IBD patients obtain dermatologic care. Given the increased risk of skin cancers among IBD patients, an emphasis on education, prevention, and screening merits attention.

Risk Factors for Community-associated Clostridium difficile-associated Diarrhea in Children.

Clostridium difficile-associated diarrhea (CDAD) is increasingly diagnosed in children in community settings. This study aims to assess recent antibiotic use and other risk factors in children with community-associated (CA-) CDAD compared with children with other diarrheal illnesses in a tertiary care setting. Children with CA-CDAD evaluated at Texas Children's Hospital (Houston, TX) from January 1, 2012 to June 30, 2013 were identified. Two control subjects with community-associated diarrhea who tested negative for C. difficile were matched to case subjects. Data on demographics, medication exposure and outpatient healthcare encounters were collected from medical records. Multivariate logistic regression was performed to identify predictors of pediatric CA-CDAD. Of 69 CA-CDAD cases, most (62.3%) had an underlying chronic medical condition and 40.6% had antibiotic exposure within 30 days of illness. However, no traditional risk factor for CDAD was identified in 23.2% and 15.9% of CA-CDAD cases within 30 and 90 days of illness onset, respectively. Outpatient healthcare encounters within 30 days were more common among CA-CDAD cases than control subjects (66.7% vs. 48.6%; P = 0.01). In the final multivariate model, CA-CDAD was associated with cephalosporin use within 30 days [odds ratio: 3.32; 95% confidence interval: 1.10-10.01] and the presence of a gastrointestinal feeding device (odds ratio: 2.59; 95% confidence interval: 1.07-6.30). Recent use of cephalosporins and the presence of gastrointestinal feeding devices are important risk factors for community- associated CDAD in children. Reduction in the use of outpatient antibiotics may decrease the burden of CA-CDAD in children.

Outpatient Provider Contact Prior to Unintentional Opioid Overdose Among VHA Service Users.

Prescription opioid medications are the most commonly implicated substances in unintentional overdoses. Outpatient health care encounters represent a potential opportunity to intervene to reduce opioid overdose risk. This study assessed the timing and type of outpatient provider contacts prior to death from unintentional prescription opioid overdose. This study examined all adult patients nationally in the Veterans Health Administration (VHA) who died from unintentional prescription opioid overdose in fiscal years 2004-2007 and who used VHA services anytime within two years of their deaths (N=1,813). For those whose final treatment contact was in an outpatient setting (N=1,457), demographic, clinical, and treatment characteristics were compared among patients categorized by the location of their last contact. Among individuals last seen in outpatient settings, 33% were seen within one week of their overdose and 62% within one month of their overdose. A substantial proportion of patients (30%) were last seen within one month of death in mental health or substance use disorder outpatient settings. The majority of patients (86%) did not fill an opioid prescription on their last outpatient visit prior to death from unintentional opioid overdose. Most patients who died by unintentional prescription opioid overdose were seen in outpatient settings within a month of their overdose. These settings may provide an opportunity to prevent patients from dying from prescription opioid overdoses. Interventions to reduce risk should not be limited to visits during which an opioid is prescribed.

Disparities in CD4+ T-Lymphocyte Monitoring Among Human Immunodeficiency Virus-Positive Medicaid Beneficiaries: Evidence of Differential Treatment at the Point of Care.

Monitoring of immune function, measured by CD4 cell count, is an essential service for people with Human Immunodeficiency Virus (HIV). Prescription of antiretroviral (ARV) medications is contingent on CD4 cell count; patients without regular CD4 monitoring are unlikely to receive ARVs when indicated. This study assesses disparities in CD4 monitoring among HIV-positive Medicaid beneficiaries. In this retrospective observational study, we examined 24 months of administrative data on 2,250 HIV-positive, continuously-enrolled fee-for-service Medicaid beneficiaries with at least two outpatient healthcare encounters. We used logistic regression to evaluate the association of patient demographics (age, gender, race/ethnicity, and language) with receipt of at least one CD4 test per year, controlling for other potentially confounding variables. Having a history of ARV therapy was positively associated with receipt of CD4 tests. We found racial/ethnic, gender, and age disparities in CD4 testing. Among individuals with a history of ARV use, all racial/ethnic groups were significantly less likely to have CD4 tests than White non-Latinos (African Americans, OR = 0.35, p<0.0001; Asian/Pacific Islanders, OR = 0.31, p=0.0047; and, Latinos, OR = 0.42, p<0.0001). Disparities in receipt of CD4 tests elucidate one potential pathway for previously reported disparities in ARV treatment. Further qualitative and quantitative research is needed to identify the specific factors that account for these disparities, so that appropriate interventions can be implemented.

Frequency, duration and predictors of bronchiolitis episodes of care among infants ≥32 weeks gestation in a large integrated healthcare system: a retrospective cohort study

BackgroundBronchiolitis is common in the first two years of life and is the most frequent cause of hospitalization in this age group. No previous studies have used an episode-of-care analysis to describe the frequency, duration, and predictors of bronchiolitis episodes of care during the first two years.MethodsWe conducted a retrospective cohort study of 123,264 infants ≥32 weeks gestation born at 6 Northern California Kaiser Permanente hospitals between 1996 and 2002. We used electronic medical records to concatenate hospital, emergency department and outpatient health care encounters for bronchiolitis into discrete episodes of care. We used descriptive statistics to report frequency and duration of bronchiolitis episodes and used logistic regression to assess the effect of gestational age and other clinical and demographic predictors on the outcome of bronchiolitis episodes.ResultsAmong all infants, the rate of bronchiolitis episodes was 162 per 1000 children during the first 2 years of life; approximately 40% required >1 day of medical attention with a mean duration of 7.0 ± 5.9 days. Prematurity was associated with increased risk of bronchiolitis episodes and longer duration. Bronchiolitis episodes rates per 1000 infants were 246 for 32–33 weeks gestational age, 204 for 34–36 weeks, and 148–178 for >36 weeks. Male gender, African-American and Hispanic race/ethnicity, and parental history of asthma were associated with an increased risk of having a bronchiolitis episode and/or longer duration.ConclusionsBronchiolitis episodes of care are frequent during the first two years of life and the duration ranges from 1 to 27 days. Prematurity was associated with more frequent and longer duration of bronchiolitis episodes of care, which may reflect illness severity and/or perceived vulnerability.

10 Clinical Decision Rules to Improve the Detection of Adverse Drug Events in Emergency Department Patients

10 Clinical Decision Rules to Improve the Detection of Adverse Drug Events in Emergency Department Patients

Outcomes of Emergency Department Patients Presenting With Adverse Drug Events

Our objectives are to describe the outcomes of patients presenting to the emergency department (ED) because of an adverse drug event and to compare them with outcomes of patients presenting for other reasons. This prospective observational study was conducted at Vancouver General Hospital, a 955-bed tertiary care hospital. We prospectively enrolled adults presenting to the ED between March and June 2006, using a systematic sampling algorithm. Pharmacists and physicians independently evaluated patients for adverse drug events. An independent committee reviewed and adjudicated cases in which assessments were discordant or uncertain. Data from the index visit were linked to vital statistics, administrative health services utilization, and cost of care data. Of 1,000 patients, 122 (12.2%; 95% confidence interval [CI] 10.3% to 14.4%) presented to the ED because of an adverse drug event. Of these, 48 presented because of an adverse drug reaction (one type of adverse drug event defined as an unintended response that occurred despite use of an appropriate drug dosage). We found no difference in mortality among patients presenting with and without adverse drug reactions (14.6% versus 5.9%; hazard ratio 1.57; 95% CI 0.70 to 3.52). After adjustment, patients with adverse drug events had a higher risk of spending additional days in the hospital per month (6.3% versus 3.4%; odds ratio 1.52; 95% CI 1.43 to 1.62) and higher rate of outpatient health care encounters (1.73 versus 1.22; rate ratio 1.20; 95% CI 1.03 to 1.40). The adjusted median monthly cost of care was 1.90 times higher (Can $325 versus $96; 95% CI 1.18 to 3.08). ED patients presenting with an adverse drug event incurred greater health services utilization and costs during a 6-month follow-up period compared with patients presenting for other reasons.