Hospital Outpatient Setting Research Articles

20 Characteristics of Medicare patients receiving peripheral vascular interventions for peripheral artery disease differ by outpatient site of service

OBJECTIVES/GOALS: Endovascular peripheral vascular interventions (PVIs) are increasingly utilized for the treatment of peripheral artery disease (PAD). We aimed to assess characteristics of patients receiving PVI at ambulatory surgical centers and office-based labs (ASC/OBL) versus the outpatient hospital (hospital) site of service. METHODS/STUDY POPULATION: We performed a retrospective analysis using 100% Medicare fee-for-service claims data between January 1, 2017 and December 31, 2022. We used Current Procedural Terminology (CPT) codes to identify patients undergoing angioplasty, stenting, or atherectomy. Patient demographics were collected from the Medicare Master Beneficiary Summary File and associated comorbidities and PVI indications were identified using International Classification of Disease (ICD)-10 codes. We used patient ZIP codes to determine patients’ residence densities and regions. We used site of service codes to determine whether PVI were performed in the ASC/OBL versus hospital. Results were analyzed with descriptive statistics. RESULTS/ANTICIPATED RESULTS: Of 817,241 patients undergoing PVI for PAD, 461,068 (56.4%) were treated in an ASC/OBL. Compared to patients treated in the hospital, patients receiving PVI at ASC/OBLs were more likely to be older, female, non-white race, with fewer comorbidities (end stage renal disease, diabetes, hypertension, and any history of tobacco use) (all, P<0.001). Patients treated in ASC/OBLs more frequently resided in urban (vs. rural) locations, and in the South and West (both, P<0.001). Indication for PVI was predominately chronic limb-threatening ischemia, and clinically similar between groups (77.1% vs. 76.2%). There was a significant change in site of service over time: a minority (47.6%) of PVIs were performed in the ASC/OBL in 2017, whereas the majority (64.7%) of PVIs were performed in the ASC/OBL in 2022 (P<0.001). DISCUSSION/SIGNIFICANCE: Patients treated in ASC/OBLs were less medically complex compared to those treated in the outpatient hospital setting. Further study is needed to examine whether differences in patient characteristics versus other factors (e.g. reimbursement) are driving the increase in PVIs performed in the ASC/OBL over time.

Downstream Revenue Realized by Facilities Placing Inflatable Penile Prosthesis in Medicare Beneficiaries to Treat Erectile Dysfunction

ObjectivesTo quantify the incremental downstream revenue generated from subsequent treatment of men who received an inflatable penile prosthesis (IPP) to treat erectile dysfunction (ED), compared to men without ED. MethodsThe 100% Medicare Standard Analytic Files were used to conduct a retrospective claims analysis of the 5-year revenue generated by patients receiving IPP to treat their ED, compared to a propensity-matched cohort of men without ED. Men aged 65 years or older with ED who underwent IPP implantation (Current Procedural Terminology® 54405) in a hospital outpatient setting between January 1, 2016 and December 31, 2021, and who had continuous Medicare Parts A and B enrollment for 12 months pre-index IPP and five years post-index IPP discharge date were included in the study. Men without ED but with comparable characteristics were identified and used as a comparator group. Revenue received by hospitals from Medicare was defined as the sum of payments for patient services, other payor-paid amounts, patient deductibles, copayments, and coinsurance. Revenue was inflated to 2022 US dollars. The mean values and their corresponding standard deviations (SD) are reported. ResultsAfter matching, there were 2,905 men with ED who received an IPP and 7,462 men without ED. The IPP cohort showed a significantly higher 5-year cumulative revenue (mean=$34,571 [SD=$50,234]) compared to the men without ED (mean=$3,189 [SD=$11,527]). When stratified by diagnosis type, the differences in revenue were $10,258 for circulatory disease, $2,646 for diabetes, $2,013 for urology, and $1,043 for prostate cancer. Significantly more IPP patients had at least one health encounter for these conditions over the 5-year follow-up period than their matched controls (55.0% versus 7.8% for circulatory, 46.7% versus 16.8% for urology, 19.3% versus 3.6% for diabetes, and 19.0% versus 3.0% for prostate cancer). ConclusionsMen with ED who received IPP generated substantially higher revenue for the healthcare system over a 5-year period, nearly ten times as much, compared to men without ED, excluding the initial cost of the IPP procedure. The presence of ED, coupled with IPP usage, is associated with significantly increased healthcare revenue across a range of medical conditions compared to men without ED. These findings emphasize the financial implications for advanced ED programs to improve access to necessary care for these patients. Healthcare facilities may leverage these insights to effectively allocate resources to deliver critical healthcare to men with ED.

Applied Artificial Intelligence in Healthcare: A Review of Computer Vision Technology Application in Hospital Settings.

Computer vision (CV), a type of artificial intelligence (AI) that uses digital videos or a sequence of images to recognize content, has been used extensively across industries in recent years. However, in the healthcare industry, its applications are limited by factors like privacy, safety, and ethical concerns. Despite this, CV has the potential to improve patient monitoring, and system efficiencies, while reducing workload. In contrast to previous reviews, we focus on the end-user applications of CV. First, we briefly review and categorize CV applications in other industries (job enhancement, surveillance and monitoring, automation, and augmented reality). We then review the developments of CV in the hospital setting, outpatient, and community settings. The recent advances in monitoring delirium, pain and sedation, patient deterioration, mechanical ventilation, mobility, patient safety, surgical applications, quantification of workload in the hospital, and monitoring for patient events outside the hospital are highlighted. To identify opportunities for future applications, we also completed journey mapping at different system levels. Lastly, we discuss the privacy, safety, and ethical considerations associated with CV and outline processes in algorithm development and testing that limit CV expansion in healthcare. This comprehensive review highlights CV applications and ideas for its expanded use in healthcare.

Barriers to implementation of smoking cessation support among healthcare professionals in the secondary healthcare sector: A qualitative and quantitative evaluation.

Smoking cessation support (SCS) in the hospital is essential; patients often struggle to maintain quit attempts, which necessitates assistance from healthcare professionals (HCPs). However, unknown barriers can obstruct the implementation of SCS in hospitals. This study aims to uncover barriers to the implementation of SCS in psychiatric, somatic, inpatient, and outpatient hospital settings. In the period from June to September 2021, HCPs in a large secondary care hospital in the Region of Southern Denmark completed an online, cross-sectional study, providing sociodemographic details and listing potential barriers to SCS. They also shared additional barriers in the form of free-text responses. Descriptive statistics and thematic analysis of free-text responses were performed. Of 1645 HCPs surveyed, 409 elaborated their response in the free-text field assessing unlisted barriers. Top listed barriers, reported by more than one-third of participants, included: 'lack of time' (45.1%), 'lack of patient motivation' (34.3%), and 'insufficient knowledge on how to support' (32.2%). Free-text responses revealed three barrier-related, which we grouped under the themes of: 'Concerned about the patient', 'Not part of my job', and 'Inappropriate setting'. This quantitative and qualitative study identifies barriers to SCS on multiple levels in the hospital setting, i.e. on the patient, provider, and organizational levels. These results can inform healthcare organizations and professionals in the implementation of SCS in routine hospital care.

(242) Medicare Beneficiaries with Erectile Dysfunction Who Receive Inflatable Penile Prosthesis: A Real-World, Downstream Revenue Analysis

Abstract Introduction Erectile dysfunction (ED) has a significant negative impact on the quality of life of patients, while also presenting challenges due to the limited access to effective treatment options. Given ED is recognized as a precursor for other chronic health conditions, increasing patient access to ED treatment through men’s health programs may provide economic benefits to a healthcare system through revenue generated from subsequent patient care for other comorbidities. Objective This study quantified the incremental downstream revenue generated from treating men with ED with an inflatable penile prosthesis (IPP) compared to men without ED. Methods This retrospective study used the 100% Medicare Standard Analytical Files to identify men aged 65 years or older with ED who underwent IPP implantation (Current Procedural Terminology 54405) in a hospital outpatient setting between January 1, 2016 and December 31, 2021. To capture 5-year downstream revenue, patients were required to have continuous Medicare Parts A and B enrollment for 12 months pre-index IPP and five years post-index IPP discharge date. Propensity score matching (PSM) was used to match men with ED who received an IPP to men without ED based on demographic and clinical characteristics. Revenue was defined as the sum of the payment for patient services received by hospitals from Medicare, other payor paid amounts, and patient deductibles, copayment, and coinsurance. The total revenue generated was estimated as follows: 1-year pre-IPP, 1-year post-IPP, and 5-year cumulative post-IPP. The 1-year and 5-year downstream revenue was captured post-IPP discharge date and excluded the revenue generated from the index IPP encounter. Revenue was inflated to 2022 US dollars. The mean values and their corresponding standard deviations (SD) were reported. Results Before PSM, the study identified 3,367 men with ED who received IPP and 10,609 men without ED or IPP (mean age: 70; White: 77% vs 79%; Southern region: 53% vs 45%; and Elixhauser comorbidity index score ≥3: 21% vs 20%). Among men undergoing IPP, the average revenue generated was $6,152 (SD: $12,934) at 1-year pre-IPP and $7,898 (SD: $17,794) at 1-year post-IPP. After PSM, the men with ED who received IPP showed a significantly higher 5-year cumulative revenue (n=2,905; mean=$34,571 [SD=$50,234]) compared to the men without ED (n=7,462; mean=$3,189 [SD=$11,527]), respectively. The 5-year cumulative average revenue varied by type of diagnosis: circulatory disease (n=1,597; cost difference=$10,258), urology (n=1,358; cost difference=$2,013), diabetes diagnosis (n=562; cost difference=$2,646), and prostate cancer diagnosis (n=551; cost difference=-$1,043). All statistical analysis results post-PSM are significant at p-value less than 0.05. Conclusions Men with ED who received IPP generated substantially higher revenue for the healthcare system over a 5-year period, nearly ten times as much, compared to men without ED, excluding the initial cost of the IPP procedure. These findings emphasize the financial implications of implementing an advanced ED program aimed at improving access to necessary care for these patients. Healthcare facilities can leverage these insights to effectively allocate resources to deliver critical healthcare to men with ED. Disclosure Yes, this is sponsored by industry/sponsor: Boston Scientific. Clarification: Industry initiated, executed and funded study. Any of the authors act as a consultant, employee or shareholder of an industry for: This study was funded by Boston Scientific. Abimbola O. Williams, Sirikan Rojanasarot, Gregory Moore, Alysha M. McGovern, Liesl M. Hargens, and Erin Turner are employees of Boston Scientific. Paurush Babbar is a practicing urologist at The Urology Group in Cincinnati, Ohio and discloses no financial interests. Andrew Sun is a practicing urologist at Urology Partners of North Texas and serves as a consultant for Boston Scientific, Endo Pharmaceuticals, and Marius Pharmaceuticals. Paurush Babbar and Andrew Sun were not compensated for their participation in this study.

Effectiveness and predictors of group cognitive behaviour therapy outcome for generalised anxiety disorder in an out-patient hospital setting.

Cognitive behavioural therapy (CBT) is an empirically supported treatment for generalized anxiety disorder (GAD). Little is known about the effectiveness of CBT for GAD in real-world treatment settings. This study investigated the effectiveness of group CBT and predictors of treatment response in an out-patient hospital clinic. Participants (n = 386) with GAD participated in 12 sessions of group CBT at an out-patient clinic. Of those who provided at least partial data (n = 326), 84.5% completed treatment. Most questionnaires were completed at pre- and post-treatment; worry severity was assessed weekly. Group CBT led to improvements in chronic worry (d = -0.91, n = 118), depressive symptoms (d = -1.22, n = 172), GAD symptom severity (d = -0.65, n = 171), intolerance of uncertainty (IU; d = -0.46, n = 174) and level of functional impairment (d = -0.35, n = 169). Greater pre-treatment GAD symptom severity (d = -0.17, n = 293), chronic worry (d = -0.20, n = 185), functional impairment (d = -0.12, n = 292), and number of comorbid diagnoses (d = -0.13, n = 299) predicted greater improvement in past week worry over treatment. Biological sex, age, depression symptom severity, number of treatment sessions attended, and IU did not predict change in past week worry over time. These findings provide support for the effectiveness of group CBT for GAD and suggest the outcomes are robust and are either not impacted or are slightly positively impacted by several demographic and clinical factors.

2052 Polypharmacy reviews in outpatient clinics - beginning the structured medication review in bone health clinic

Abstract Introduction Inappropriate polypharmacy is recognised as a contributing factor towards adverse outcomes in frail patients. Current efforts at national level are centred around primary care initiatives in completing structured medication reviews (SMR) where shared decision making takes place with open discussion around risks and benefits of treatments. The aim of this review was to assess whether recommendations for discussion in SMR have been adopted for patients attending frailty bone health clinic led by Consultant Pharmacist, in hospital outpatient setting. Method Retrospective analysis of notes was undertaken in a sample of 30 patients reviewed in clinic in the period 01.09.22-28.02.23 who were on at least five medications, were still alive six months post review and where suggestions with regards to actions to discuss during a structured medication review were made. Results Average age of patients sampled was 79 years with average CFS of 5.75. Number of medicines documented at outpatient appointment was on average 10.6 which reduced to 9.95 at review six months after the appointment. Around a third of recommendations were adapted fully, with another third partially completed and a third not completed. Interventions included review of falls risk increasing drugs (FRIDs), reduction of anticholinergic load, identification of possible prescribing cascades, review of opioid medication in chronic pain context and review of medicines where benefit may no longer be derived due to frailty progression. In cases where review of medication with high anticholinergic load was advised, an average reduction of -3 was achieved at six-month review. Conclusion(s) Starting a structured medication review in outpatient clinic has the potential to reduce the risk of adverse events and improve outcomes for patients. Further work will be undertaken to ascertain reasons for not adopting the recommendations and continuous collaboration with primary care colleagues will continue to address problematic polypharmacy.

Effect of Thoracic Mobility with Breath Stacking Exercise on Chest Expansion in Postsurgery Breast Cancer Patients: A Pilot Study

Context: Breast cancer is the most prevalent cancer among women accounting for nearly 14% of all types of cancer for which the therapeutic procedure modified radical mastectomy is frequently performed on patients. Postsurgery patients are prone to having incision or suture site pain that will interfere with chest expansion. Aim: The aim of this study was to determine the effectiveness of thoracic mobility exercises along with the breath stacking technique on chest expansion in breast cancer patients. Settings and Design: It was an experimental study carried out in an outpatient hospital setting. Subjects and Methods: A total of 46 participants eligible as per inclusion criteria were randomly assigned into 2 groups using a simple random sampling method. During the study period, Group A, the experimental group (n = 23), received thoracic mobility and breath stacking technique and the conventional group (n = 23) received thoracic mobility exercises alone. Pre- and postchest expansion was determined using a tape measure at the axillary and xiphisternum levels. Statistical analysis used: Data were analyzed using MS Excel on Windows 10 and usingStatistical Package for the Social Sciences (SPSS) version 21 (Armonk, NY: IBM Corp). Baseline data for participants in the experimental and comparison groups were summarized using descriptive statistics. Descriptive statistics included frequencies, percentages, mean, and standard deviation. Results: Chest circumference score at axillary and xiphisternum levels significantly improved in the intervention group after 4 weeks of the rehabilitation program (P < 0.05). Conclusions: The present study concludes that thoracic mobility exercises along with the breath stacking technique are beneficial for improving chest expansion in postsurgery breast cancer patients.

Psychometric evaluation of the Danish version of the Pain Self-Efficacy Questionnaire in patients with subacute and chronic low back pain.

The Pain Self-Efficacy Questionnaire (PSEQ) is a widely used patient-reported outcome measure designed to assess the level of pain self-efficacy in patients with low back pain (LBP). Although the PSEQ has been translated into Danish, its measurement properties remain unknown in patients with subacute and chronic LBP in Danish outpatient clinics. The aim of this study was to investigate the construct validity, internal consistency, test-retest reliability, and measurement error of the Danish version of the PSEQ in a group of Danish patients with subacute and chronic LBP in a hospital outpatient setting. Patients with LBP referred to two Danish outpatient clinics were recruited for this study. Two days after the consultation, the participants were emailed a link to a survey that included the following outcome measures: the PSEQ, the Oswestry Disability Index, the Numeric Pain Rating Scale, and the Tampa Scale of Kinesiophobia. Five days after completion of the survey, a new survey that included the PSEQ was sent to the participants. In total, 109 participants were included for the analysis of construct validity and internal consistency, with 94 participants included for the analysis of test-retest reliability and measurement error. Construct validity was found to be high and internal consistency was acceptable, with Cronbach's alpha = 0.93 (95% confidence interval [CI] = 0.91-0.93). Test-retest reliability was found to be good, with an intraclass correlation coefficient (ICC2.1) of 0.89 (95% CI = 0.82-0.92). The standard error of measurement was calculated to be 4.52 and the smallest detectable change was 12.5 points. The Danish version of the PSEQ showed acceptable measurement properties in terms of construct validity, internal consistency, and test-retest reliability in a group of patients with subacute and chronic LBP. However, further studies are needed to investigate other aspects of the measurement properties.

Trends in performance of hospital outpatient procedures and associated 30-day costs among Medicare beneficiaries from 2011 to 2018

BackgroundUnited States healthcare has increasingly transitioned to outpatient care delivery. The degree to which Academic Medical Centers (AMCs) have been able to shift surgical procedures from inpatient to outpatient settings despite higher patient complexity is unknown. MethodsThis observational study used a 20% sample of fee-for-service Medicare beneficiaries age 65 and older undergoing eight elective procedures from 2011 to 2018 to model trends in procedure site (hospital outpatient vs. inpatient) and 30-day standardized Medicare costs, overall and by hospital teaching status. ResultsOf the 1,222,845 procedures, 15.9% occurred at AMCs. There was a 2.42% per-year adjusted increase (95% CI 2.39%–2.45%; p < .001) in proportion of outpatient hospital procedures, from 68.9% in 2011 to 85.4% in 2018. Adjusted 30-day standardized costs declined from $18,122 to $14,353, (-$560/year, 95% CI -$573 to -$547; p < .001). Patients at AMCs had more chronic conditions and higher predicted annual mortality. AMCs had a lower proportion of outpatient procedures in all years compared to non-AMCs, a difference that was statistically significant but small in magnitude. AMCs had higher costs compared to non-AMCs and a lesser decline over time (p < .001 for the interaction). AMCs and non-AMCs saw a similar decline in 30-day mortality. ConclusionsThere has been a substantial shift toward outpatient procedures among Medicare beneficiaries with a decrease in total 30-day Medicare spending as well as 30-day mortality. Despite a higher complexity population, AMCs shifted procedures to the outpatient hospital setting at a similar rate as non-AMCs. ImplicationsThe trend toward outpatient procedural care and lower spending has been observed broadly across AMCs and non-AMCs, suggesting that Medicare beneficiaries have benefited from more efficient delivery of procedural care across academic and community hospitals.

Breastfeeding experiences of patients in baby-friendly certified hospital settings: protocol for a scoping review

IntroductionThe Baby-friendly Hospital Initiative is a global programme that is meant to support breastfeeding within organisations. Most of the current literature is focused on implementation and uptake of the programme;...

Unintentional weight loss is reflected in worse one-year clinical outcomes among COPD outpatients

Unintentional weight loss (UWL) is prevalent among patients with chronic obstructive pulmonary disease (COPD). However, little research has been done on UWL as an independent variable in terms of clinical outcome. The aim of this study was to investigate the association between BMI, UWL, and clinical outcome in terms of hospitalization, length of stay, exacerbations, mortality, and quality of life (QoL) within six months and one year in a hospital outpatient setting. A prospective single-center cohort study enrolled 200 patients from the COPD outpatient clinic between October 2020 and May 2021at a Danish Hospital. At baseline, data was collected using patients' electronic journals and a quantitative questionnaire was gathered with a patient-reported UWL of 5% of body weight within three months. At six months and one-year follow-ups, data was collected using the patients' medical journals and a telephonic interview with the EQ-5D-5L and SARC-F questionnaire and the number of non-hospitalization exacerbations since inclusion. Data were analyzed using logistic and Cox hazard regression analysis. A total of 187 patients were eligible for follow-up (mean age 69.2 years, 43.9% males, median BMI 26.8kg/m2), and the prevalence of UWL was 13.4%. UWL was associated with an almost trifold risk of >five days stay (OR=2.94, p=0.021). Additionally, UWL was associated with a worse QoL. A higher risk of exacerbation was found in the underweight patients (OR=4.94, p=0.014). No significant difference in mortality was found. UWL as a solitary factor is associated with increased hospital length of stay and a worse QoL. The results provide further evidence that implementation of regular screening for UWL in addition to BMI might be beneficial to include in international COPD guidelines for outpatient settings.

Greater executive dysfunction in patients post-COVID-19 compared to those not infected

BackgroundA number of patients post-coronavirus disease-19 (COVID-19) report cognitive impairment (CI), even months after acute infection. We aimed to assess if COVID-19 is associated with increased incidence of CI in comparison to controls. MethodsWe analyzed data from the Mount Sinai Health System Post-COVID-19 Registry in New York City, a prospective cohort of patients post-COVID-19 ≥18 years of age and non-infected controls. CI was defined by scores ≥ 1.0 standard deviation below population norms, and was assessed using well-validated measures of attention, working memory, processing speed, executive functioning/cognitive flexibility, language, learning, and memory. Logistic regression models assessed odds for CI in each domain in patients post-COVID-19 vs. controls after adjusting for potential confounders. In exploratory analyses, we assessed odds for CI by site of acute COVID-19 care as a proxy for disease severity. Findings417 patients post-COVID-19 and 151 controls (mean age 49 years, 63% female, 21% Black, 17% Latinx) were included. In adjusted analyses, patients were significantly more likely than controls to have CI in executive functioning (odds ratio [OR]: 2.19; 95% confidence interval [CI]: 1.03 to 4.67), particularly those treated in outpatient (OR: 2.22; 95% CI: 1.02 to 4.82) and inpatient hospital (OR: 3.59; 95% CI: 1.27 to 10.16) settings. There were no significant associations between CI in other domains and history of COVID-19 or site of acute care. InterpretationPatients post-COVID-19 have greater odds of executive dysfunction, suggesting that focused cognitive screening may be prudent, even in those with mild to moderate disease. Studies should explore the pathophysiology and potential treatments for CI in this population. FundingThis work was funded by the Icahn School of Medicine at Mount Sinai.

Transnasal Esophagoscopy (TNE) procedure in the outpatient clinic at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia

Link of Video Abstract: https://youtu.be/nk1qtXzfl7I Background: Transnasal esophagoscopy (TNE) is a small-caliber flexible esophagoscopy technique with the same diagnostic accuracy as conventional esophagoscopy. In addition, this technique is safer than any other technique and has patient tolerance. This study aims to analyze and evaluate the TNE procedure in patients. Methods: a retrospective approach was used in this study by taking data from the activity register of the broncho-eschatology division of the outpatient unit of ORL-HNS Dr. Soetomo General Academic Hospital. TNE report book and patient medical records were collected to have the data. The observation period was from 2013 to 2017. Data were analyzed using SPSS version 25.0 for Windows. Results: patients met the inclusion and exclusion criteria were 99 patients, with a male-to-female ratio of 2.3: 1. Most endoscopic findings were normal esophagus (56.57%). Existing abnormal findings included esophageal stenosis (18.18%), esophageal mucosal lesions (14.14%), and esophageal tumors (11.11%). TNE examination complications were found to be 1%. Conclusion: TNE is widely used in patients aged 51-60, with dysphagia, reflux or Globus as the most common indications. TNE is quite safe to do in an outpatient hospital setting.

Growth of community-based immunotherapy treatment in the Veterans Health Administration.

The MISSION and CHOICE Acts expanded the Veterans Health Administration's (VA) capacity to purchase immunotherapy services for VA patients from community-based providers. Our objective was to identify predictors of community-based immunotherapy treatment, and assess differences in cost and utilization across community treatment settings METHODS: We examined claims for 21,257 patients who started immunotherapy treatment between 2015 and 2020. We assessed growth in VA community-based immunotherapy care, predictors of community-based immunotherapy treatment using multivariable logistic regression based on patients' sociodemographic and clinical characteristics. We compared utilization and costs among those who received community-based immunotherapy services in hospital outpatient departments (HOPDs) versus physician office settings (POs). The proportion of community-based immunotherapy in the VA increased from 5.3% in 2015 to 32.1% in 2020, with total annual costs of immunotherapy growing from $6.1 million to $187 million. Older, married, and rural patients and those with more comorbidities were more likely than younger, single, or urban patients to be treated in the community. Black patients were more likely to be treated in the VA. Respiratory Cancer was the most common cancer type in both settings. Among community immunotherapy patients, we observed no meaningful differences in the number of units administered, the unit drug costs, or the cost per immunotherapy visit between POs and HOPDs. Drug costs did not differ widely across HOPDs and POs among VA patients who receive community-based immunotherapy.

Hips in cerebral palsy: A clinico-radiological evaluation of hip subluxation in cerebral palsy

BackgroundThe study was done on children with cerebral palsy in the ages of 2–18 years, with focus on hip subluxation. The objectives of the study were to look at the distribution of different types of CP in the target population; the prevalence of hip subluxation and its association with types and severity of CP. MethodsThis is a cross sectional descriptive observational study, done on a hospital out-patient setting. Children with cerebral palsy of ages 2–18 years were recruited and clinically evaluated. Radiological evaluation of the pelvis was done for all subjects. Primary outcome measure was presence of hip subluxation described as Migration Percentage >30% in one or both hips. Prevalence of subluxation and its association with various subtypes of CP were assessed. Results203 subjects with cerebral palsy underwent the study. Spastic type of presentation constituted the majority (82.8%). Quadriplegic distribution (53.2%) and functional level of GMFCS 5 (39.4%) were most prevalent. Hip subluxation was noted in 105 of the 203 children with CP (51.7%). 3 patients had complete dislocation of the hip (1.4%). There was an increased prevalence of hip subluxation noted with increasing GMFCS E&R score as well as increasing topographical distribution, which were both statistically significant on univariate analysis (p < 0.005). On multivariate analysis, it was found that neither topographical distribution nor GMFCS E&R score were independent risk factors. ConclusionsHip subluxation is a significant, debilitating and common treatable complication in children with CP. Subjects with widespread topographical distribution and poor functional ambulatory status are at an increased risk of developing hip subluxation. There also exists a correlation between GMFCS scores and topographical classification and hence, neither are risk factors independent of each other. This study is a first of its kind in the Indian scenario and it hopes to be a step in the direction towards risk stratification, early diagnosis and prompt specific treatment of hip complications in children with cerebral palsy.

Home versus outpatient hospital intravenous immunoglobulin infusion and health care resource utilization

BackgroundHome health care delivery is projected to increase. Intravenous immunoglobulin (IVIG) therapy has high potential to move from the outpatient hospital (OPH) setting to home delivery. ObjectiveThis study examined the relationship between home and OPH IVIG infusions and health care utilization. MethodsWe used a retrospective cohort study design and the Humana Research Database to identify patients with 1 or more medical or pharmacy claims for an IVIG infusion agent from January 1, 2017, to December 31, 2018. Eligible patients were enrolled in a Medicare Advantage Prescription Drug (MAPD) or commercial health plan, with at least 12 months of continuous enrollment before and after their first infusion (i.e., index date) received in the home or OPH setting. We measured the odds of experiencing an inpatient (IP) stay or emergency department (ED) visit, adjusted for baseline differences in age, sex, race, region, population density, low-income, and dual eligibility status, MAPD or commercial health plan, plan type, treatment-naïve status, home health use, RxRisk-V comorbidity burden score, and indications for IVIG use. ResultsA total of 208 and 1079 patients received IVIG infusions in the home and OPH setting, respectively. The odds for an IP stay (odds ratio [OR] 0.56 [95% CI 0.38–0.82]) and ED visit (OR 0.62 [95% CI 0.41–0.93]) were significantly lower in patients who received IVIG infusion in the home than patients receiving infusion in the OPH setting. ConclusionsOur findings suggest there may be value to increasing referrals for IVIG home infusion. Decreased health care utilization provides value to the system in cost savings and to patients and families owing to less disruption and improved clinical outcomes. Further study can help inform health policy designed to maximize the benefits of IVIG home infusion while minimizing potential risks.

Poster 199: Rate of arthroscopic rotator cuff repair performed at ambulatory surgery centers remains low despite significant cost savings for the healthcare system

Objectives: The objectives of this study are to 1) understand the differences in costs between rotator cuff repair (RCR) performed in ambulatory surgery center (ASC) versus outpatient hospital (OH) settings; 2) determine the patient’s out-of-pocket expenditure and surgeon reimbursement; and 3) characterize trends in expenditure for RCR over time. Methods: We identified patients who had undergone outpatient arthroscopic RCR in the United States (U.S.) using the IBM MarketScan Commercial Claims and Encounters Database. The database was chosen for its large, national sample of privately insured patients. Patients who had Current Procedural Terminology (CPT) code 29827 between April 1, 2013 and June 30, 2018 were included. Revision RCR procedures and procedures with a concomitant arthroscopic or open biceps tenodesis, Bankart repair, superior labrum anterior and posterior (SLAP) repair, lysis of adhesions (CPT: 29828, 23430, 29806, 29807, 29825) were excluded. Day-of-surgery expenditure was identified by summing all claims billed with an “immediate-procedure-related code” in a 3-day window surrounding the date of the procedure (Procedure Date ± 1 Day). The day-of-surgery expenditure was broken down into anesthesia services, nerve block, operating room facility, surgical team, patient out-of-pocket expenditure, and other expenditures. Median and interquartile range were calculated for each variable. The breakdown of day- of-surgery expenditure and patient out-of-pocket expenditure between the OH and ASC settings were compared using two-tailed Mann Whitney U Tests. Spearman Rank Order Correlation was done for all variables to test for association between expenditure and year to determine trends over time. All values were inflation adjusted to 2018 dollars using the consumer price index for medical care. Results: A total of 43,020 patients were identified; 24,850 in the OH setting and 18,170 in the ASC setting. This converts to an ASC utilization of 42 percent over the study period. In 2018, ASC utilization was at 45%. We found that RCR performed in the OH setting resulted in 55% greater day-of-surgery expenditure (p&lt;0.001) than in the ASC setting. In the OH setting, operating room facility cost was 35% greater (p &lt;0.001), anesthesia services was 7.4% greater (p&lt;0.001), but nerve block was 2.4% lower (p&lt;0.001) (Figure 1). Additionally, for RCRs performed in the OH setting, Spearman coefficients demonstrated that immediate procedure cost (rho = 0.209, p &lt; 0.001) increased along with expenditure for anesthesia services (rho = 0.085, p &lt; 0.001), nerve block (rho = 0.135, p &lt; 0.001), and operating room facility cost (rho = 0.108, p &lt; 0.001) over our study period. For RCRs performed in the ASC setting, immediate procedure cost (rho = 0.309, p &lt; 0.001) increased along with expenditure for anesthesia services (rho = 0.116, p &lt; 0.001), nerve block (rho = 0.086, p &lt; 0.001), and operating room facility cost (rho = 0.148, p &lt; 0.001). Surgical team reimbursement was 6.3% greater in the ASC setting (p &lt; 0.001), but decreased over time in both the ASC (rho = -0.069, p &lt; 0.001) and OH (rho = -0.046, p &lt; 0.001) settings. Lastly, there was no difference in patient out-of-pocket expenditure for RCRs performed in the OH setting vs. ASC setting (Table 1). However, patient out-of-pocket expenditure for RCRs is increasing in both settings (OH: rho = 0.147, p &lt; 0.001; ASC: rho = 0.203, p &lt; 0.001). Conclusions: RCR performed in an ASC setting results in significant cost savings for payers with a slight change in surgeon reimbursement and no change in patient-out-of-pocket expenditure. Most of the cost savings came from operating room facility expenditure. For the surgeon, surgical team reimbursements are higher in the ASC setting. However, the overall trend in surgical team reimbursement is downwards in both the ASC and OH settings whereas the cost per RCR to the healthcare system is increasing. Thus, surgeon reimbursement is becoming a smaller percentage of the immediate procedure cost and should not be further cut when policy makers evaluate strategies to decrease the economic burden of RCRs on the healthcare system, especially when the cost savings from performing a RCR far outweigh both the amount the surgeon is reimbursed as well as the difference in surgeon reimbursement between an ASC and OH. For a healthcare system, especially under a population health perspective, the incentive to perform RCRs at an ASC is significant. The cost savings come from almost every breakdown category. The cost savings achieved per RCR in an ASC vs. an OH equals about $4,000. With nearly 400,000 RCRs performed per year, the U.S. healthcare system could save a projected $1.6 billion per year on RCRs alone when the surgery is performed in an ASC. Thus, our study shows that there is a clear financial advantage to the healthcare system for RCRs being done at ASCs, although the patient does not realize these cost savings. [Table: see text]

A mini-review of robotic applications for lower-limb rehabilitation in Malaysia

In recent years, advancements in robotic technology have found diverse applications in providing healthcare support to individuals, spanning inpatient care, hospital outpatient services and community settings. The rapid progress in the development of gait-training robots, including exoskeletons and other lower-limb robotic devices, holds significant promise for patients dealing with motor and gait dysfunction resulting from conditions such as stroke, traumatic brain injury, spinal cord injury and cerebral palsy. This mini-review offers a short summary and assessment of the latest information on current applications of robotics in lower-limb rehabilitation in Malaysia. The review not only summarises recent developments but also identifies gaps in existing studies, shedding light on areas that require further exploration. In addition, the review provides valuable suggestions for future research efforts. By addressing these knowledge gaps, the field of robotic-assisted lower-limb rehabilitation in Malaysia can evolve, offering patients more efficient, advanced and readily accessible rehabilitation options. Collaborative efforts between researchers and professionals, focussing on both technological innovations and clinical aspects, have the potential to significantly improve the quality of life of the affected community in Malaysia and worldwide.

Advance care plans for vulnerable and disadvantaged adults: systematic review and narrative synthesis

BackgroundEvidence suggests that there is a gap in advance care planning (ACP) completion between vulnerable and disadvantaged populations compared with the general population. This review seeks to identify tools, guidelines...