Patient-level Predictors Research Articles

Drug retention of biologic and targeted synthetic disease-modifying antirheumatic drugs in Korean patients with seropositive rheumatoid arthritis.

The aim of this study was to compare the short- and long-term retention rates of biologic and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) in Korean patients with seropositive rheumatoid arthritis. This study was conducted with 1,538 treatment courses of 1,063 patients, including adalimumab (n = 332), etanercept (n = 369), infliximab (n = 146), abatacept (n = 152), tocilizumab (n = 299), tofacitinib (n = 136), and baricitinib (n = 104), in patients with seropositive rheumatoid arthritis who started b/tsDMARD treatment between 2008 and 2020 at Seoul St. Mary's Hospital. Discontinuation 1 and 3 years after the first prescription of each drug was investigated. Kaplan- Meier estimates of time to discontinuation were calculated to compare the difference in drug retention rate for each drug. Patient-level predictors of drug discontinuation were evaluated using a Cox proportional hazards model. The overall 1-year drug retention rate was from 60.1% for adalimumab to 90.0% for tofacitinib in the b/tsDMARD-naïve group, and from 55.2% for infliximab to 84.8% for tofacitinib in the b/tsDMARD-experienced group. The 3-year drug retention rate was from 36.9% for infliximab to 86.5% for tofacitinib in the b/tsDMARD-naïve group, and from 31.0% for infliximab to 65.4% for tocilizumab in the b/tsDMARD-experienced group. Drug discontinuation appeared to be affected by specific types of b/tsDMARDs. Tocilizumab and tofacitinib are less commonly discontinued compared to tumor necrosis factor-α inhibitors at 1 and 3 years. Specifically, tofacitinib in the b/tsDMARD-naïve group and tocilizumab in the b/tsDMARD-experienced group showed the highest 3-year retention rates.

Factors influencing diabetes treatment satisfaction in the INtegrating DEPrEssioN and Diabetes treatmENT randomized clinical trial: A multilevel model analysis.

Patient satisfaction is associated with positive diabetes outcomes. However, there are no identified studies that evaluate both patient- and clinic-level predictors influencing diabetes care satisfaction longitudinally. Data from the INtegrating DEPrEssioN and Diabetes treatmENT trial was used to perform the analysis. We used fixed and random effects models to assess whether and how changes in patient-level predictors (treatment assignment, depression symptom severity, systolic blood pressure, body mass index, LDL cholesterol, and haemoglobin A1C) from 0 to 24 months and clinic-level predictors (visit frequency, visit cost, number of specialists, wait time, time spent with healthcare provider, and receiving verbal reminders) measured at 24 months influence diabetes care satisfaction from 0 to 24 months. Model 1 (patient-level predictors) accounted for 7% of the change in diabetes satisfaction and there was a significant negative relationship between change in depressive symptoms and care satisfaction (β = -0.23, SE = 0.12, p < 0.05). Within Model 1, 2% of the variance was explained by clinic-level predictors. Model 2 included both patient- and clinic-level predictors and accounted for 18% of the change in diabetes care satisfaction. Within Model 2, 9% of the variance was attributed to clinic-level predictors. There was also a cross-level interaction where the change in depression had less of an impact on the change in satisfaction for those who received a verbal reminder (β = -0.11, SE = 0.21, p = 0.34) compared with those who did not receive a reminder (β = -0.62, SE = 0.08, p < 0.01). Increased burden of depressive symptoms influences diabetes care satisfaction. Clinic-level predictors also significantly influence diabetes care satisfaction and can reduce dissatisfaction in primary care, specifically, reminder calls from clinic staff.

Patterns of gabapentinoid use among long-term opioid users

ObjectiveUnderstanding the clinical and demographic profile of patients on gabapentinoids can highlight areas of prescribing disparities, inform clinical practice, and guide future research to optimize effectiveness and safety of gabapentinoids for pain management. We used a national sample of Medicare beneficiaries to examine trends, patterns, and patient-level predictors of gabapentinoid use among long-term opioid users. MethodsUsing a national Medicare sample between 2014 and 2020, we examined factors associated with gabapentinoid use among long-term opioid users. We included Medicare eligible long-term opioid users with no prior gabapentinoid use. The primary outcome was gabapentinoid use after the long-term opioid use episode. Logistic regression was used to test the association with gabapentinoid use for year, age, sex, race/ethnicity, region, Medicare entitlement, low-income status, frailty, pain locations, anxiety, depression, opioid use disorder, and opioid morphine milligrams equivalent. ResultsGabapentinoid use among long-term opioid users increased from 12.6% in 2014 to 16.8% in 2019 (p < .0001). Factors associated with increased gabapentinoid use were Hispanic ethnicity, back pain, nerve pain, and moderate or high opioid usage. Factors associated with decreased gabapentinoid use were older age and Medicare entitlement due to old age. ConclusionsVariation of gabapentinoid use by socio-demographics and insurance status indicates opportunities to improve pain management and a need for shared therapeutic decision making informed by discussion between pain patients and providers regarding safety and effectiveness of pain therapies. Our findings underscore the need for future research into the comparative effectiveness and safety of gabapentinoids for non-cancer chronic pain in various subpopulations.

Testing effectiveness and implementation of a standardized approach to sexual dysfunction screening among adolescent and young adult-aged survivors of childhood cancer: A type I hybrid, mixed methods trial protocol: Effectiveness of sexual dysfunction screening among AYA cancer survivors: a study protocol.

Approximately 20-50% of adolescent and young adult-aged childhood cancer survivors (AYA-CCS) experience sexual dysfunction (SD), although this healthcare need is widely underrecognized. Previous research from both AYA-CCS patients and their providers report that SD needs are unaddressed despite patient desires for SD discussions to be incorporated as part of their care. Patients and providers agree that standardized use of a patient-reported outcome measure may facilitate SD discussions; an SD screening approach was developed with patient and provider input. This study will measure the effectiveness of a standardized SD screening intervention and assess implementation outcomes and multilevel barriers and facilitators to guide future research. This multi-site, mixed methods, type 1 effectiveness-implementation hybrid trial will be evaluated using a pre-post design (NCT05524610). The trial will enroll 86 AYA-CCS (ages 15-39) from two cancer centers in the United States. The SD intervention consists of core fundamental functions with a "menu" of intervention options to allow for flexibility in delivery and tailoring in variable contexts. Effectiveness of the intervention on facilitating SD communication will be measured through patient surveys and clinical data; multivariable logistic regression will be used for the binary outcome of self-reported SD screening, controlling for patient-level predictors. Implementation outcomes will be assessed using mixed methods (electronic health record abstraction, patient and provider surveys, and provider interviews. Quantitative and qualitative findings will be merged using a joint display to understand factors affecting intervention success. Identification and treatment of SD in AYA-CCS is an important and challenging quality of life concern. The type 1 hybrid design will facilitate rapid translation from research to practice by testing the effects of the intervention while simultaneously identifying multilevel barriers and facilitators to real-world implementation. This approach will inform future testing and dissemination of the SD screening intervention.

Patient-Level and Physician-level Predictors of Discharge Against Medical Advice: A Multilevel Modeling Approach

Background: Discharge Against Medical Advice (DAMA) is a complex and multifaceted issue in healthcare, often challenging the continuity of care and affecting patient outcomes. Objectives: This study aimed to investigate the predictors of Discharge Against Medical Advice (DAMA) by simultaneously examining patient- and physician-level variables within a unified analytical framework. Methods: This cross-sectional study was conducted in 2023 at one of the largest private hospitals in northwest Iran. The study included all 16,071 patients admitted in 2022 and 137 attending physicians. A multilevel analysis model was employed to examine the influence of variables related to patients and physicians in predicting DAMA. Results: The study involved patients with a mean age of 45.28 ± 19.59 years, with 67.7% being women and 14.8% not having health insurance. Among the physicians studied, the mean age was 56.27 ± 12.29 years, with 67.2% being male and 70.1% being hospital shareholders. Patients with DAMA comprised 6.8% (n = 1094). The null model had a log-likelihood value of -3304.90. When patient-level predictors were added, the value increased to -3041.76, a statistically significant improvement (P &lt; 0.001) based on the chi-square test. Subsequently, incorporating physician-level predictors further increased the log-likelihood value to -2996.16, and this increase was also statistically significant compared to the model with only patient-level predictors (P &lt; 0.001). Physician-level factors, including specialization, sex, and experience, were associated with DAMA. Significant patient-level variables included age, type of insurance, and type of disease (P &lt; 0.05). Conclusions: Utilizing multilevel modeling enables the assessment of the significance of both physician-level and patient-level factors. To avoid conflicting results, it is recommended to evaluate hospital performance based on DAMA by considering both levels.

Analysis of missed clinic visits, preferred languages, and telemedicine in a pediatric gastroenterology practice.

Previous studies have demonstrated a relationship between socioeconomic disparities and missed clinic visits (MCV). However, the relationship between patient-preferred language and MCVs, particularly with respect to telemedicine, remains relatively underexplored. We sought to characterize the associations between MCV and patient-level predictors, including preferred language, in a large single-center pediatric gastroenterology, hepatology, and nutrition practice. This retrospective longitudinal cohort study included all missed or completed outpatient visits in the Gastroenterology, Hepatology, and Nutrition Programs at Boston Children's Hospital from January 1, 2016to May 20, 2022. Univariate and multivariate hierarchical generalized linear mixed models were employed to identify associations between visit- and patient-level predictors and an MCV outcome. A total of 300,201 visits from 70,710 patients residing in Massachusetts were included. Univariate analyses revealed higher MCV odds for Hispanic patients and those from areas with the highest Social Vulnerability Index (SVI), and these odds increased with telemedicine (Hispanic in-person odds ratio [OR] 5.21 [(95% confidence interval) 4.93-5.52] vs. telemedicine OR 8.79 [7.85-9.83]; highest SVI in-person OR 5.28 [4.95-5.64] vs. telemedicine OR 7.82 [6.84-8.96]). Controlled multivariate analyses revealed that among six language groups, only Spanish language preference was associated with higher MCV odds, which increased with telemedicine (Spanish in-person adjusted OR [aOR]1.35 [1.24-1.48] vs. telemedicine aOR 2.1 [1.83-2.44]). Patients preferring Spanish experience unique barriers to care beyond those faced by other language preference groups, and telemedicine may exacerbate these barriers.

Interfacility Transfer Outcomes Among Children With Complex Chronic Conditions: Associations Between Patient-Level and Hospital-Level Factors and Transfer Outcomes.

Determine patient- and referring hospital-level predictors of transfer outcomes among children with 1 or more complex chronic conditions (CCCs) transferred to a large academic medical center. We conducted a retrospective chart review of 2063 pediatric inpatient admissions from 2017 to 2019 with at least 1 CCC defined by International Classification of Diseases, Tenth Revision codes. Charts were excluded if patients were admitted via any route other than transfer from a referring hospital's emergency department or inpatient ward. Patient-level factors were race/ethnicity, payer, and area median income. Hospital-level factors included the clinician type initiating transfer and whether the referring-hospital had an inpatient pediatric ward. Transfer outcomes were rapid response within 24 hours of admission, Pediatric Early Warning Score at admission, and hours to arrival. Regression analyses adjusted for age were used to determine association between patient- and hospital-level predictors with transfer outcomes. There were no significant associations between patient-level predictors and transfer outcomes. Hospital-level adjusted analyses indicated that transfers from hospitals without inpatient pediatrics wards had lower odds of ICU admission during hospitalization (odds ratio, 0.46; 95% confidence interval, 0.22-0.97) and shorter transfer times (β-coefficient, -2.54; 95% CI, -3.60 to -1.49) versus transfers from hospitals with inpatient pediatrics wards. There were no significant associations between clinician type and transfer outcomes. For pediatric patients with CCCs, patient-level predictors were not associated with clinical outcomes. Transfers from hospitals without inpatient pediatric wards were less likely to require ICU admission and had shorter interfacility transfer times compared with those from hospitals with inpatient pediatrics wards.

Hospital Variation in Skilled Nursing Facility Use After Coronary Artery Bypass Graft Surgery.

Over 20% of patients are discharged to a skilled nursing facility (SNF) after coronary artery bypass graft surgery, but little is known about specific drivers for postdischarge SNF use. The purpose of this study was to evaluate hospital variation in SNF use and its association with postoperative outcomes after coronary artery bypass graft. A retrospective study design utilizing Medicare Provider Analysis and Review files was used to evaluate SNF use among 70 509 beneficiaries undergoing coronary artery bypass graft, with or without valve procedures, between 2016 and 2018. A total of 17 328 (24.6%) were discharged to a SNF, ranging from 0% to 88% across 871 hospitals. Multilevel logistic regression models identified significant patient-level predictors of discharge to SNF including increasing age, comorbidities, female sex, Black race, dual eligibility, and postoperative complications. After adjusting for patient and hospital factors, 15.6% of the variation in hospital SNF use was attributed to the discharging hospital. Compared with the lower quartile of hospital SNF use, hospitals in the top quartile of SNF use had lower risk-adjusted 1-year mortality (12.5% versus 8.6%, P<0.001) and readmission (59.9% versus 49.8%, P<0.001) rates for patients discharged to a SNF. There is high variability in SNF use among hospitals that is only partially explained by patient characteristics. Hospitals with higher SNF utilization had lower risk-adjusted 1-year mortality and readmission rates for patients discharged to a SNF. More work is needed to better understand underlying provider and hospital-level factors contributing to SNF use variability.

Using machine learning to predict acute myocardial infarction and ischemic heart disease in primary care cardiovascular patients.

Early recognition, which preferably happens in primary care, is the most important tool to combat cardiovascular disease (CVD). This study aims to predict acute myocardial infarction (AMI) and ischemic heart disease (IHD) using Machine Learning (ML) in primary care cardiovascular patients. We compare the ML-models' performance with that of the common SMART algorithm and discuss clinical implications. Patient-level medical record data (n = 13,218) collected between 2011-2021 from 90 GP-practices were used to construct two random forest models (one for AMI and one for IHD) as well as a linear model based on the SMART risk prediction algorithm as a suitable comparator. The data contained patient-level predictors, including demographics, procedures, medications, biometrics, and diagnosis. Temporal cross-validation was used to assess performance. Furthermore, predictors that contributed most to the ML-models' accuracy were identified. The ML-model predicting AMI had an accuracy of 0.97, a sensitivity of 0.67, a specificity of 1.00 and a precision of 0.99. The AUC was 0.96 and the Brier score was 0.03. The IHD-model had similar performance. In both ML-models anticoagulants/antiplatelet use, systolic blood pressure, mean blood glucose, and eGFR contributed most to model accuracy. For both outcomes, the SMART algorithm was substantially outperformed by ML on all metrics. Our findings underline the potential of using ML for CVD prediction purposes in primary care, although the interpretation of predictors can be difficult. Clinicians, patients, and researchers might benefit from transitioning to using ML-models in support of individualized predictions by primary care physicians and subsequent (secondary) prevention.

Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative.

We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics. We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient. Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%). Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.

Sustained high fatality during TB therapy amid rapid decline in TB mortality at population level: A retrospective cohort and ecological analysis from Shiselweni, Eswatini.

Despite declining TB notifications in Southern Africa, TB-related deaths remain high. We describe patient- and population-level trends in TB-related deaths in Eswatini over a period of 11 years. Patient-level (retrospective cohort, from 2009 to 2019) and population-level (ecological analysis, 2009-2017) predictors and rates of TB-related deaths were analysed in HIV-negative and HIV-coinfected first-line TB treatment cases and the population of the Shiselweni region. Patient-level TB treatment data, and population and HIV prevalence estimates were combined to obtain stratified annual mortality rates. Multivariable Poisson regressions models were fitted to identify patient-level and population-level predictors of deaths. Of 11,883 TB treatment cases, 1302 (11.0%) patients died during treatment: 210/2798 (7.5%) HIV-negative patients, 984/8443 (11.7%) people living with HIV (PLHIV), and 108/642 (16.8%) patients with unknown HIV-status. The treatment case fatality ratio remained above 10% in most years. At patient-level, fatality risk was higher in PLHIV (aRR 1.74, 1.51-2.02), and for older age and extra-pulmonary TB irrespective of HIV-status. For PLHIV, fatality risk was higher for TB retreatment cases (aRR 1.38, 1.18-1.61) and patients without antiretroviral therapy (aRR 1.70, 1.47-1.97). It decreases with increasing higher CD4 strata and the programmatic availability of TB-LAM testing (aRR 0.65, 0.35-0.90). At population-level, mortality rates decreased 6.4-fold (-147/100,000 population) between 2009 (174/100,000) and 2017 (27/100,000), coinciding with a decline in TB treatment cases (2785 in 2009 to 497 in 2017). Although the absolute decline in mortality rates was most pronounced in PLHIV (-826/100,000 vs. HIV-negative: -23/100,000), the relative population-level mortality risk remained higher in PLHIV (aRR 4.68, 3.25-6.72) compared to the HIV-negative population. TB-related mortality rapidly decreased at population-level and most pronounced in PLHIV. However, case fatality among TB treatment cases remained high. Further strategies to reduce active TB disease and introduce improved TB therapies are warranted.

Abstract 18569: Patient and Provider Factors Associated With the Initiation of Sodium-Glucose Cotransporter-2 Inhibitors (SGLT2i) in the Year Post FDA Approval for HFpEF and HFmrEF

Introduction: Despite robust evidence for, and Food and Drug Administration (FDA) approval of sodium-glucose cotransporter-2 inhibitors (SGLT2i) for heart failure with preserved and mildly reduced ejection fraction (HFpEF/HFmrEF), use of this therapy is suboptimal. Hypothesis: We aimed to determine 1) prescribing context (inpatient/outpatient) and prescriber type of SGLT2i; 2) patient and provider level predictors of SGLT2i prescription in the year following FDA approval. Methods: All patients in a diverse, multi-state (Ohio and Florida), multi practice/hospital integrated system who had least 1 ambulatory encounter for HF and documented EF &gt; 40% were included. Data come from the electronic health record. We compared patients who were prescribed SGLT2i in the year post FDA approval 2/24/22-2/24/23 against those who were not using multivariable logistic regression to assess independent predictors of SGLT2i prescription. Results: 20,255 patients with HFpEF/HFmrEF were included in the study. Mean age 73±9 yrs, female (49.8%), Black (17.4%), DM2 (34%), AFib (43%), CKD (35%), baseline medications: BB (52.4%), ACEi/ARB (41%), MRA (19.7%), ARNI (6.5%), SGLT2i (3.2%). There were 1118 (5.6%) patients were newly prescribed SGLT2i in the study period. SGLT2i were most commonly initiated by cardiology 54.2%, general medicine 25.3% and endocrinology 8.5%. Of prescriptions, 82.9% were outpatient, 17.1% inpatient. Independent patient level predictors of SGLT2i prescription were DM2 2.82 (2.09-3.82), p&lt;0.001; AFib 1.42 (1.07-1.92), p=0.018; higher eGFR 1.16 (1.09-1.25), p&lt;0.001 and increasing EF 0.88 (0.81-0.97), p&lt;0.001. Insurance type/median income were not significant. Provider level predictors were total HF visits with each specialty: HF cardiology, 1.21 (1.13-1.29), p&lt;0.001; general cardiology, 1.1 (1.04-1.15), p&lt;0.001; and primary care, 1.1 (1.08-1.17), p&lt;0.001. After excluding patients with DM2, predictors were total visits with HF specialists, and general cardiologists. Conclusions: In the year post FDA approval, there has been significant underutilization of SGLT2i. Diabetes status and provider factors were associated with SGLT2i use, the majority of which were initiated in the outpatient setting by cardiology providers.

Relative Risk Regression for Clustered Data with Application to Oral Health Research

Introduction: Cluster-weighted generalized estimating equations (CWGEE) and doubly-weighted GEE (DWGEE) are used to produce unbiased estimates when informative cluster size (ICS) exists. However, their performance in estimating the relative risk (RR) from a Poisson regression is unknown. Methods: Using the dental data from the San Juan Overweight Adults Longitudinal Study (SOALS), we estimated the association between patient-level (sex, education level, smoking status, age) and tooth-level (bleeding upon probing) predictors and two types of outcomes with high and low prevalence each. We compared the odds ratio (OR) and RR estimates from logistic and Poisson CWGEE/DWGEE, respectively. Results: For patient-level covariates, the ORs estimated from logistic CWGEE/DWGEE and the RRs estimated from Poisson CWGEE/DWGEE were similar to the low-prevalence outcome (tooth loss). With the high-prevalence outcome (tooth loss or increase in attachment loss or pocket depth), the ORs were further from the null compared to the RRs. For example, within CWGEE, the OR of smoking was 1.301 (95% CI: 1.063-1.592), whereas the RR of smoking was 1.235 (95% CI: 1.052-1.450). For the tooth-level covariate (bleeding), there was a considerable difference between OR/RR on tooth loss estimated from CWGEE vs DWGEE. For example, the RR estimated from CWGEE was 1.692 (95% CI: 1.386-2.067), whereas the RR estimated from DWGEE was 1.354 (95% CI: 1.072-1.710). Discussion: CWGEE and DWGEE may produce different estimates for tooth-level (sub-cluster) covariates, especially when the prevalence of the outcome is low. In general, RRs estimated from Poisson CWGEE/DWGEE are closer to the null compared to ORs estimated from logistic CWGEE/DWGEE.

Predictors of initial management failure in traumatic hemothorax: A prospective multicenter cohort analysis

BackgroundTraumatic hemothorax is common, and management failure leads to worse outcomes. We sought to determine predictive factors and understand the role of trauma center performance in hemothorax management failure. MethodsWe prospectively examined initial hemothorax management (observation, pleural drainage, surgery) and failure requiring secondary intervention in 17 trauma centers. We defined hemothorax management failure requiring secondary intervention as thrombolytic administration, tube thoracostomy, image-guided drainage, or surgery after failure of the initial management strategy at the discretion of the treating trauma surgeon. Patient-level predictors of hemothorax management failure requiring secondary intervention were identified for 2 subgroups: initial observation and immediate pleural drainage. Trauma centers were divided into quartiles by hemothorax management failure requiring secondary intervention rate and hierarchical logistic regression quantified variation. ResultsOf 995 hemothoraces in 967 patients, 186 (19%) developed hemothorax management failure requiring secondary intervention. The frequency of hemothorax management failure requiring secondary intervention increased from observation to pleural drainage to surgical intervention (12%, 22%, and 35%, respectively). The number of ribs fractured (odds ratio 1.12 per fracture; 95% confidence interval 1.00–1.26) and pulmonary contusion (odds ratio 2.25, 95% confidence interval 1.03–4.91) predicted hemothorax management failure requiring secondary intervention in the observation subgroup, whereas chest injury severity (odds ratio 1.58; 95% confidence interval 1.17–2.12) and initial hemothorax volume evacuated (odds ratio 1.10 per 100 mL; 95% confidence interval 1.05–1.16) predicted hemothorax management failure requiring secondary intervention after pleural drainage. After adjusting for patient characteristics in the logistic regression model for hemothorax management failure requiring secondary intervention, patients treated at high hemothorax management failure requiring secondary intervention trauma centers were 6 times more likely to undergo an intervention after initial hemothorax management failure than patients treated in low hemothorax management failure requiring secondary intervention trauma centers (odds ratio 6.18, 95% confidence interval 3.41–11.21). ConclusionFailure of initial management of traumatic hemothorax is common and highly variable across trauma centers. Assessing patient selection for a given management strategy and center-level practices represent opportunities to improve outcomes from traumatic hemothorax.

Emergency department visits within 90 days of lumbar discectomy

BACKGROUND CONTEXTLumbar discectomy is a common procedure following which emergency department (ED) visits may occur. Although many quality improvement initiatives target reemissions, ED visits may be more common, be a marker of quality of care, affect patient satisfaction, and contribute to health-care resource utilization and costs. PURPOSETo analyze the timing and risk factors predicting ED utilization following lumbar discectomy and thereby facilitate better-targeted risk reduction. STUDY DESIGN/SETTINGRetrospective database review of the 2010 to April 30th, 2021, M157Ortho PearlDiver dataset. PATIENT SAMPLESingle-level lumbar laminotomy/discectomy between 2010 and April 30th, 2021, in the PearlDiver M157Ortho dataset. OUTCOME MEASURESFunctional measures—ED utilization in the 90 days following lumbar discectomy, patient-level predictors for ED utilization, and number and type of reoperations performed in the 90 days following lumbar discectomy. METHODSLumbar laminotomies/discectomies were identified. Patients were excluded if additional procedures were performed or if there was not 90-day follow-up in the dataset. Patient factors were extracted, including age, sex, Elixhauser comorbidity index (ECI), region of the country in which their procedure was performed (Midwest, Northeast, South, West), and patient insurance plan (Commercial, Medicaid, Medicare). The incidence, timing, and frequency of ED utilization within 90 days of lumbar discectomy were then determined. Cohort average weekly ED utilization at 1-year postoperatively was calculated as a baseline for reference. Patient factors predictive of postoperative ED utilization were then determined with univariate and multivariate analyses. Primary diagnoses for ED visits were also categorized. Patients who underwent reoperation for complications related to lumbar discectomy following ED visits were determined, and types of reoperation procedures were characterized. RESULTSOf 281,103 lumbar discectomy patients identified, ED visits within 90 days of surgery were identified for 28,632 (10.2%). Of note, 40.4% of these ED visits occurred in the first 2 postoperative weeks. Multivariate analysis revealed several independent predictors of ED utilization following lumbar discectomy, including: younger age (odds ratio [OR] 1.21 per decade decrease), female sex (OR 1.12 relative to male), higher ECI (OR 1.42 per 2-point increase), having surgery performed in the Northeast, Midwest, or West United States (OR 1.05, 1.17, and 1.13, respectively, relative to South), and Medicaid coverage (OR 1.89 relative to Medicare). Forty-three percent of ED visits were surgical site related, of which surgical site pain predominated at 34.2% of overall reasons. Of patients who visited the ED, 943 (3.3%) underwent reoperation in the subsequent 2 weeks. Laminectomy with nerve root decompression was the most performed reoperation (30.9%), followed by incision and drainage (22.5%), posterior nonsegmental instrumentation (10.3%), laminectomy facetectomy and foraminotomy (9.97%), repair of dural/CSF leak or pseudomeningocele with laminectomy (9.3%), repair of dural/CSF leak not requiring laminectomy (8.9%), arthrodesis (4.3%), and posterior segmental instrumentation (3.9%). CONCLUSIONSFollowing lumbar discectomy, over 1 in 10 patients were found to visit the ED in the 90 days following their surgery, most commonly in the first 2 postoperative weeks. Specific patient characteristics were associated with such ED visits, with the most common primary diagnoses among ED visitors being surgical site pain. About 3.3% of patients who visited the ED underwent reoperation in the subsequent 2 weeks. Through identification of the timing, risk factors, primary reasons for, and risk of reoperation following ED utilization in the 90-day period after lumbar discectomy, care pathways can be modified to improve patient satisfaction, outcomes, and reduce excess health-care expenditures.

Predictors of Revascularization in Lower-Extremity Peripheral Artery Disease: Insights From the PORTRAIT Study.

Peripheral artery disease (PAD) guidelines recommend revascularization only for patients with lifestyle-limiting claudication that is refractory to goal-directed medical therapy (class IIA, level of evidence A). However, real-world invasive treatment patterns and predictors of revascularization in patients with symptomatic lower-extremity PAD are still largely unknown. We aimed to examine rates, patient-level predictors, and site variability of early revascularization in patients with new or worsening PAD symptoms. Among patients with new-onset or recent exacerbation of PAD in the 10-center Patient-centered Outcomes Related to TReatment practices in peripheral Arterial disease: Investigating Trajectories (PORTRAIT) study enrolled between June 2011 and September 2015, we classified early revascularization (endovascular or surgical) as procedures being performed within 3 months of presentation. Hierarchical logistic regression was used to identify patient characteristics associated with early revascularization. Variability across sites was estimated using the median odds ratio (OR). Among 797 participants, early revascularization procedures were performed in 224 (28.1%). Rutherford class 3 (vs Rutherford class 1; OR=1.86, 95% confidence interval [CI] 1.04-3.33) and having lesions in both iliofemoral and below-the-knee arterial segments (vs below the knee only; OR=1.75, 95% CI: 1.15-2.67) were associated with a higher odds of revascularization. Longer PAD duration >12 months (vs 1-6 months; OR=0.50, 95% CI: 0.32-0.77), higher ankle-brachial index scores (per 0.1 unit increase; OR=0.86, 95% CI: 0.78-0.96), and higher Peripheral Artery Questionnaire Summary scores (per 10 unit increase; OR=0.89, 95% CI: 0.80-0.99) were associated with a lower odds of revascularization. The raw rates for revascularization in different sites ranged from 6.25% to 66.28%, and the median OR was 1.88, 95% CI: 1.38-3.57. About 1 in 3 patients with symptomatic PAD received early revascularization. A more extensive disease and symptom burden were the main predictors of receiving early revascularization in PAD. There was significant site variability in revascularization patterns, and further studies will better understand the source of this variability and optimal selection criteria for early revascularization. Real world patterns and predictors of early revascularization in peripheral artery disease are not well understood. In this retrospective analysis of the POTRAIT study, about 1 out of 3 patients with PAD symptoms received early revascularization, with significant site variability. A more extensive disease and symptom burden were the main predictors of receiving early revascularization in PAD.

The Relationship Between an Individual's Birthday and Admission for Traumatic Injury.

Birthdays provide an opportunity to celebrate; however, they can also be associated with various adverse medical events. This is the first study to examine the association between birthdays and in-hospital trauma team evaluation. This retrospective study analyzed trauma registry patients 19-89years of age, who were evaluated by in-hospital trauma services from 1/1/2011 to 12/31/2021. 14,796 patients were analyzed and an association between trauma evaluation and birthdays was found. The strongest incidence rate ratios (IRRs) were on the day of birth (IRR: 1.78; P < .001) followed by ±3days of the birthday (IRR: 1.21; P = .003). When incidence was analyzed by age groups, 19-36years of age had the strongest IRR (2.30; P < .001) on their birthday, followed by the >65 groups (IRR: 1.34; P = .008) within ±3days. Non-significant associations were seen in the 37-55 (IRR: 1.41; P = .209) and 56-65 groups (IRR: 1.60; P = .172) on their birthday. Patient-level characteristics were only significant for the presence of ethanol at trauma evaluation (risk ratio: 1.83; P = .017). Birthdays and trauma evaluations were found to have a group-dependent association, with the greatest incidence for the youngest age group being on their birthday, and the oldest age group within ±3days. The presence of alcohol was found to be the best patient-level predictor of trauma evaluation.

MP18-15 PERSPECTIVES OF YOUNG MEN WITH SPINA BIFIDA ON FERTILITY POTENTIAL AND FUTURE PARENTHOOD

You have accessJournal of UrologyCME1 Apr 2023MP18-15 PERSPECTIVES OF YOUNG MEN WITH SPINA BIFIDA ON FERTILITY POTENTIAL AND FUTURE PARENTHOOD James Rague, Josephine Hirsch, Theresa Meyer, Courtney Streur, Ilina Rosoklija, Stephanie Kielb, Earl Cheng, Diana Bowen, Elizabeth Yerkes, and David Chu James RagueJames Rague More articles by this author , Josephine HirschJosephine Hirsch More articles by this author , Theresa MeyerTheresa Meyer More articles by this author , Courtney StreurCourtney Streur More articles by this author , Ilina RosoklijaIlina Rosoklija More articles by this author , Stephanie KielbStephanie Kielb More articles by this author , Earl ChengEarl Cheng More articles by this author , Diana BowenDiana Bowen More articles by this author , Elizabeth YerkesElizabeth Yerkes More articles by this author , and David ChuDavid Chu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003238.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior studies have suggested that young men with spina bifida (SB) are interested in parenthood. However, physiologic barriers to achieving parenthood have been identified, including sexual dysfunction and poor sperm quality, with varying reported rates of successful paternity. Patient-level predictors of and concerns about future fertility remain poorly understood, including perceived psychosocial barriers to parenthood, limiting the ability to provide early counseling to patients. We aimed to assess the perspectives of young men with SB on fertility potential and future parenthood. METHODS: Semi-structured qualitative interviews were conducted between 2/2021 and 5/2021 with men ≥18 years of age with a diagnosis of SB about knowledge or fertility potential and perspectives on future paternity. Demographic and clinical characteristics were obtained from a patient survey and chart review. Interviews were transcribed verbatim, and inductive and deductive qualitative coding was performed. Codes were summarized into themes, with representative quotes, until thematic saturation. RESULTS: Of 30 eligible patients approached, 20 ultimately were interviewed. Median participant age was 22.5 years (range 18-29), and 80% had a diagnosis of myelomeningocele. Most reported not being in a relationship (14/20, 70%), identifying as heterosexual (17/20, 85%), and not being currently sexually active (13/20, 65%). No patient reported a history of paternity. Many participants reported a desire for future fertility but for various reasons were not currently ready for fatherhood. Perceived barriers to achieving parenthood were identified, including: 1) uncertainty around fertility potential; 2) uncertainty of the hereditary nature of SB; and 3) specific concerns with being a parent and raising a child. Facilitators to help overcome uncertainty and perceived challenges with parenthood were also identified with themes and representative quotations outlined in the Figure 1. CONCLUSIONS: Men with SB report interest in future fertility, yet express great uncertainty regarding physiologic and psychosocial ability to be a parent. Facilitators of patient uncertainty should be a focus of patient counseling around future fertility with young men with SB. Source of Funding: Partial support from NIDDK K23 award to Dr. Chu © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e229 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Rague More articles by this author Josephine Hirsch More articles by this author Theresa Meyer More articles by this author Courtney Streur More articles by this author Ilina Rosoklija More articles by this author Stephanie Kielb More articles by this author Earl Cheng More articles by this author Diana Bowen More articles by this author Elizabeth Yerkes More articles by this author David Chu More articles by this author Expand All Advertisement PDF downloadLoading ...

Abstract P4-03-25: Patient-level predictors of skipping screening mammograms during the COVID-19 pandemic at a large tertiary care center in Texas

Abstract Background: Following the declaration of the COVID-19 national emergency, screening mammograms (SM) abruptly dropped across the United States. Stay-at-home orders discourage cancer patients from seeking care, and cancer screenings and surgeries were postponed. Upon resumption of screening services, rates of screening were slow to recover. At Baylor St. Luke’s CHI (BSL), one of the largest tertiary care centers providing comprehensive cancer screening in Houston, we investigated patient level predictors, including comorbidities and area deprivation index (ADI), and the risk of skipping SM in the first year of the COVID-19 Pandemic. Methods: We used the local PENRAD database to retrieve the monthly gross number of SM performed at all BSL sites from 02/2018 to 01/2021. We obtained patient level data through EPIC, including address and demographics, comorbid conditions e.g., diabetes, hypertension, obesity (BMI30), chronic kidney disease and cardiovascular diseases (CVD). We identified ADI associated with patient addresses. We included patient who received at least one SM between 02/2018 to 01/2020. We compared patients did not get a mammogram in the first year of the pandemic; 02/2020 to 01/2021, to those who maintained screening during the pandemic. We performed a logistic regression analysis to assess the influence of age, 0 to +3 comorbid conditions, and ADI in quartiles on the odds ratio of skipping SM in the first year of the pandemic. Statistical significance was set at p&amp;lt; 0.05. The study was IRB approved. Results: Out of the 4591 women that screened in 2018 and/or 2019, only 1628 came back for SM in 2020 (35.5%). Women who obtained SM during the pandemic vs those who did not were slightly older, mean age 58 vs 56 (P&amp;lt; 0.001), were less likely to be living in the most deprived neighborhood, Q4 of ADI, 23.8% vs. 25.6%, more likely to be obese 39% vs. 35% (P&amp;lt; 0.001), more likely to have diabetes 48% vs. 41% (P&amp;lt; 0.001), more likely to have CVD, 16% vs. 13% (P&amp;lt; 0.001), and more likely to have hypertension 80% vs. 71% (P&amp;lt; 0.001). On multivariate logistic regression, living in Q4 ADI was associated with 22% higher risk of skipping SM in 2020 (95% CI 1.02-1.42), having one vs. two vs. three comorbid conditions increased the likelihood of obtaining SM in 2020 by 25% (95% CI 0.62-0.91) vs. 30% vs (95% CI 0.58-0.85), 42% (95% CI 0.48-0.7) compared to no comorbid conditions. Conclusion: Women living in Q4 of the ADI (most deprived neighborhood) were more likely to miss 2020 screening when compared with the Q1 women (least deprived neighborhood). The more chronic diseases women had, the less likely they were to skip 2020 screening when compared with those that had no chronic disease. This could because women with many health issues have to frequent health facilities at higher rates and thus less likely to miss mammograms. Citation Format: Maryam Nemati Shafaee, Omar Rosales, Randall Parker Kirby, Tamara Ortiz-Perez, Luke Gilman, Ashley Hardeman, Preeya Bhavsar Bhakta, Chris Amos, Abiodun Oluyomi. Patient-level predictors of skipping screening mammograms during the COVID-19 pandemic at a large tertiary care center in Texas [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-03-25.

Abstract P563: Exploring Facility and Patient-Level Determinants of Changes in Systolic Blood Pressure Among Patients With Hypertension: A Multicenter Study in Ghana

Background: Optimal blood pressure control is essential in averting complications and associated cardiovascular risks. Although a 5-mmHg reduction in systolic blood pressure (SBP) is associated with better health outcomes, individual-level and health facility dynamics might influence optimal blood pressure control. We explored individual and health facility-level factors of SBP changes among patients with hypertension in Ghana. Methods: We recruited 15 health facilities that provided hypertension care and from each facility, 15 patients who were currently receiving hypertension care during their clinic appointment. We explored patient-level (adherence to treatment, length of time with hypertension diagnosis, and sociodemographic factors) and health-facility level (accessibility of care, health facility management, bed capacity, provider training, and provider-patient ratio) predictors. We fitted two-level mixed-effect linear regression models to identify predictors of SBP changes. Results: We included 222 patients, 81% were female, and 48% had achieved blood pressure control of &lt; 140/90 mmHg. At the patient level, secondary-level education was associated with a 7.5 mmHg (95% CI: -14.74, -0.28) greater reduction in SBP than a primary or lower level of education (Table). Patients treated at private facilities had on average 15.8 mmHg (95% CI: 4.97, 26.62) higher SBP than those in government health facilities. Patients who were receiving care at health facilities where a physician or physician assistant treated ≥ 280 patients/month had 28.4 mmHg (95% CI: 9.77, 46.97) higher SBP than those receiving care from a physician/physician assistant who cared for &lt; 140 patients/month. Conclusion: Health system interventions to address individual barriers, the shortage of healthcare providers, and team-based care strategies are needed to address the burden of hypertension in Ghana.