Payer Status Research Articles

2033. Use of Sterile, Single-Use Bronchoscopes Reduces Procedure-Associated Readmissions Rates and Eliminates Potential Device Cross-Contamination

Abstract Background Improper reprocessing of reusable bronchoscopes poses a serious patient safety risk. The risk of patient infection resulting from use of contaminated bronchoscopes has been reported to be 2.8%. By virtue of being sterile, SFB eliminates device-related infection risk, subsequent readmission rates, and associated costs. Readmissions following bronchoscopy may occur for many reasons, but most frequently are due to infection, bleeding, or pain. These infections are preventable and can be eliminated with the use of a sterile, single-use bronchoscope when the device is used according to the manufacturer’s instructions for use. Methods Bronchoscopies with SFB and RFB were identified along with their corresponding readmission information in the Premier Healthcare Database from 2016- 2019. A logistic regression analysis was conducted with 30-day readmission as the dependent variable. Independent variables included use of a RFB, gender, race, age, payer, and discharge status. For the inpatient setting, the 3M™ APR DRG Severity of Illness classification was included as an independent variable. 30 Day Readmissions Results A total of 14,228 procedures were identified, of which 1,795 used SFB and 12,433 used a RFB. In the inpatient setting, the RFB group was ∼2.5 times more likely to be readmitted within 30 days compared to the SFB group (OR=2.5, p< 0.01), controlling for patient demographics and risk. In the outpatient setting, the RFB group was ∼1.5 times more likely to be readmitted than the SFB group (OR=1.5, p >0.05). Across all settings, the RFB group was ∼2.3 times more likely to be readmitted than the SFB group (OR=2.3, p< 0.01). The inability to fully risk-adjust in the outpatient setting may have been a factor in the smaller OR and lack of statistical significance; this limitation will be addressed with further analysis that includes an outpatient severity of illness classification variable. Conclusion Patients undergoing bronchoscopy typically have significant comorbidities which increase their risk for the development of potential device-related infections. To reduce these risks, the use of a sterile SFB should be considered to eliminate reprocessing failures, improve overall operational efficiency, and reduce potential acquisition of healthcare-associated infections. Disclosures John H. Garrett, PhD, MSN, MPH, MBA, FNP-BC, FNAP, FSHEA, FIDSA, Aerobiotix: Advisor/Consultant|Ambu: Advisor/Consultant|American Academy of Nurse Practitioners: Honoraria|Clorox Pro: Advisor/Consultant.

Transfer patient imaging: secondary interpretation reimbursement.

Trauma center radiologists vary widely in the degree to which they provide secondary interpretations for transferred patients' advanced imaging. A general perception of uncertainty over reimbursement for these exams often results in reluctance to provide routine overreads. The purpose of this study is to assess the difference in reimbursement rates between primary interpretations and secondary interpretations in the emergency department (ED) setting. Billing records for the three CT procedures most commonly performed in a single, major level 1 trauma center ED from January 1, 2021, to December 31, 2021, constituted the dataset. Gross charges, total receipts, and payer status were recorded for each exam, and reimbursement rates calculated. In total, 19,754 exams met the inclusion criteria. Primary interpretation was performed on 16,507 (83.6%) exams and secondary interpretation on 3247 (16.4%). For the three CPT codes examined, the average reimbursement percentage was 32.9% for primary interpretation and 43.5% for secondary interpretation. The average reimbursement percentage for commercial payers was 56.5% for primary interpretation and 65.9% for secondary interpretation. The average reimbursement percentage for Health Insurance Exchange payers was 58.5% for primary interpretation and 59.5% for secondary interpretation. The average reimbursement percentage for Medicaid was 24.7% for primary interpretation and 39.9% for secondary interpretation. The average reimbursement percentage for Medicare was 31.1% for primary interpretation and 30.2% for secondary interpretation. The average reimbursement percentage for self-paying patients was 2.3% for primary interpretation and 3.5% for secondary interpretation. Regardless of payer status, reimbursement for secondary interpretation of the three most common transfer patients' CT exams is near or greater than that of primary interpretations.

Post-Acute Care Use Associated with Medicare Shared Savings Program and Disparities.

Medicare Shared Savings Program (MSSP) was implemented in 2012, but the impact of the MSSP on institutional post-acute care (PAC) use, and by race/ethnicity and payer status is less studied. We studied the impact of hospital participation in the MSSP on institutional PAC use and variations by race/ethnicity and payer status among 3 Medicare patient groups: ischemic stroke, hip fracture, and elective total joint arthroplasty (TJA). A retrospective analysis of 2010-2016 Medicare Provider Analysis and Review files. Medicare fee-for-service patients originally admitted for ischemic stroke, hip fracture, or elective TJA in MSSP-participating hospitals or nonparticipating hospitals. Patient-level linear probability models with difference-in-differences approach were used to compare the changes in institutional PAC use in MSSP-participating hospitals with nonparticipating hospitals as well as to compare the changes in differences by race/ethnicity and payer status in institutional PAC use over time. Hospital participation in MSSP was significantly associated with increased institutional PAC use for the ischemic stroke cohort by 1.5 percentage points [95% confidence interval (CI) 0.00-0.3, P < .05] compared with non-MSSP participating hospitals. Regarding variations by race/ethnicity and payer status, for the elective TJA patients, racial minority patients in MSSP-participating hospitals had 3.8 percentage points greater (95% CI 0.01-0.06, P < .01) in institutional PAC use than white patients. Also, for ischemic stroke cohort, dual-eligible patients in MSSP-participating hospitals had 2.0 percentage points greater (95% CI 0.00-0.04, P < .10) in institutional PAC use than Medicare-only patients. This study found that hospital participation in the MSSP was associated with slightly increased institutional PAC use for ischemic stroke Medicare patients. Also, compared to non-MSSP participating hospitals, MSSP-participating hospitals were more likely to discharge racial minority patients for elective TJA and dual-eligible patients for ischemic stroke to institutional PAC.

Examining changes in clinical management and postpartum readmissions for hypertensive disorders of pregnancy over time.

In response to 2013 guidelines for hypertensive disorders of pregnancy (HDP), our study examined changes in antenatal management and postpartum readmission (PPR) over time. This is a retrospective cohort study of individuals diagnosed antenatally with HDP who delivered at a tertiary care center from 2012 to 2017. The primary outcome was postpartum readmission for HDP in 2012-2013 vs 2014-2017. Secondary outcomes included intravenous magnesium administration and prescription for oral (PO) antihypertensive medication during delivery admission. Multivariable logistic regression models assessed differences in outcomes over time, adjusted for age, race, and payer status, for HDP with and without severe features, defined by ACOG criteria. Of 5,300 eligible individuals, 73.5% had HDP without severe features and 26.5% had severe features. The PPR frequency in this cohort was 1.1% (N=59). There was no difference in PPR for individuals with HDP without severe features (aOR 0.73; 95% CI 0.28-1.88) or with severe features (aOR 1.30; 95% CI 0.50-3.39) by epoch. Magnesium administration for HDP with severe features remained below 80% over time. Magnesium administration for HDP without severe features and discharge prescriptions for PO medications for HDP with severe features were lower after 2013. Neither magnesium administration nor discharge prescriptions were associated with decreased odds of PPR. Although there was no difference in PPR for HDP after 2013, there were changes in antenatal management of HDP, including decreased magnesium administration for individuals with HDP without severe features and PO medication for individuals with severe features.

S5 Characteristics and Outcomes of Patients With IBD Admitted to High vs Low Safety Net Burden Hospitals: A Nationwide Analysis

Background: Inflammatory bowel disease (IBD), is a chronic relapsing inflammatory disorder that requires a meticulous multidisciplinary management approach. This may prove difficult in safety net hospitals, and it is unclear if a hospital’s safety net burden (SNB) is associated with outcomes. The aim of this study was to investigate the effect of hospital SNB on in-hospital mortality, length of stay, and hospitalization cost in patients with IBD. Methods: We used the National Inpatient Sample (NIS) to identify all adult hospitalizations with IBD from 2016 to 2018. SNB was calculated as the percentage of hospitalizations with Medicaid or uninsured payer status for each hospital in the 2016-2018 database. Multivariable models were used to compare outcomes of admissions to hospitals with low SNB (lowest tertile, <18.1%) hospitals with high SNB (highest tertile, >31.1%). Results: The demographic and clinical characteristics for the 106,603 patients hospitalized with IBD are shown in Table 1 (see poster). Of all patients, 42.3% were admitted to low SNB hospitals and 57.7% were admitted to high SNB hospitals. The main study outcomes (in-hospital mortality, length of stay, and cost) are shown in Table 2 (see poster). In-hospital mortality was 1.4% in low SNB hospitals and 1.6% in high SNB hospitals (adjusted OR = 1.15, 95% CI 1.03-1.29, P = 0.016). Mean length of stay was longer in high SNB hospitals compared to low SNB hospitals (5.6 vs 5.1 days, adjusted mean difference 0.38 days, P < 0.0001). Low SNB hospitals had higher hospitalization costs compared to high SNB hospitals ($15,968 vs $15,670, adjusted mean difference $402, P = 0.01). Conclusion(s): In this large population of inpatients with IBD, patients admitted to high SNB hospitals had overall worse hospital mortality and longer length of stay. Patients admitted to low SNB hospitals had higher hospital costs. Further research is needed to clarify the cause of these discrepant outcomes in IBD hospitalizations, and specific interventions are needed to improve the delivery of care to IBD patients in high SNB hospitals.

Racial and Ethnic Disparity in Prehospital Pain Management for Trauma Patients.

Although evidence suggests that racial and ethnic minority (REM) patients receive inadequate pain management in the acute care setting, it remains unclear whether these disparities also occur during the prehospital period. The aim of this study is to assess the impact of race and ethnicity on prehospital analgesic use by emergency medical services (EMS) in trauma patients. Retrospective chart review of adult trauma patients aged 18 to 89 years old transported by EMS to our American College of Surgeons-verified level 1 trauma center from 2014 to 2020. Patients who identified as Black, Asian, Native American, or Other for race and/or Hispanic or Latino or Unknown for ethnicity were considered REM. Patients who identified as White, non-Hispanic were considered White. Groups were compared in univariate and multivariate analysis. The primary outcome was prehospital analgesic administration. A total of 2,476 patients were transported by EMS (47% White and 53% REM). White patients were older on average (46 years vs 38 years; p < 0.001) and had higher rates of blunt trauma (76% vs 60%; p < 0.001). There were no differences in Injury Severity Score (21 vs 20; p = 0.22). Although REM patients reported higher subjective pain rating (7.2 vs 6.6; p = 0.002), they were less likely to get prehospital pain medication (24% vs 35%; p < 0.001), and that difference remained significant after controlling for baseline characteristics, transport method, pain rating, prehospital hypotension, and payor status (adjusted odds ratio [95% CI], 0.67 [0.47 to 0.96]; p = 0.03). Patients from racial and ethnic minority groups were less likely to receive prehospital pain medication after traumatic injury than White patients. Forms of conscious and unconscious bias contributing to this inequity need to be identified and addressed.

The effect of socioeconomic factors on patient outcomes in cardiac surgery.

Healthcare delivery is heterogenous; the reasons for this are numerous and complex. Patient-specific factors including geography, income, insurance status, age, and gender have been shown to bias surgical outcomes. Utilizing a prospectively collected all-payer database, we aim to evaluate the influence of socioeconomic factors on mortality and length of stay (LOS) after common cardiac surgical procedures. We utilized the National Inpatient Sample,Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for the year 2019. We included patients undergoing coronary artery bypass grafting (CABG), aortic valve replacement (AVR), transcatheter aortic valve replacement (TAVR), and combined AVR/CABG using the 10th revision of the International Classification of Diseasesprocedure codes. AVR and CABG were combined into a separate cohort as this was felt to represent a different pathology than isolated valvular or coronary arterial disease. Baseline demographics were summarized. Multivariable regression was performed within each procedure group to model the odds of in-hospital mortality and hospital LOS with age, sex, insurance, zip-code median household income, and location as predictors. Baseline patient characteristics including gender, income, geography, and payer status were similar between CABG, AVR, and AVR/CABG. TAVR patients had a higher proportion of female sex and Medicare as the primary payer, with an overall greater age. Multivariable Cox proportional hazards regression found that higher income was strongly associated with decreased LOS following AVR and CABG, and moderately associated in TAVR and AVR/CABG. Private insurance was associated with a decreased LOS in patients undergoing CABG, AVR, TAVR, and AVR/CABG. Female sex and increased age were associated with increased odds of mortality in TAVR, CABG, and AVR/CABG. Private insurance was associated with a decreased odds of mortality in patients undergoing AVR. These findings reveal significant disparities in patient outcomes after routine cardiac operations that are associated with socioeconomic status. Patients who did not have private insurance or had lower incomes were found to be at risk for increased LOS. Women were at a higher risk of mortality for several operations, a finding which has been previously described elsewhere. Private insurance conveyed a decreased odds of mortality in patients undergoing AVR. This data set serves to highlight differences in healthcare outcomes based on a variety of socioeconomic, geographic, and other inherent factors. Additional research is needed to identify the mechanisms behind these disparities with the goal of providing equitable care to all patients.

Pediatric Age at Hematopoietic Stem Cell Transplant: Associations with Non-Malignant Genetic Disease and Race

Introduction: Increasingly, hematopoietic stem cell transplant (HSCT) is used in pediatrics to treat both malignant and nonmalignant conditions. Many of the nonmalignant disorders for which HSCT is curative are genetic, and it has long been recognized that the diagnostic odyssey for patients with genetic disorders is frequently quite long. Notably, the diagnostic odyssey is longer for non-white patients with genetic diseases than for white patients with genetic diseases. We hypothesized that this disparity would also manifest as older age at time of HSCT, which could be associated with greater co-morbidities and worse outcomes. While previous studies have analyzed the association between race and pediatric HSCT access and survival, (PMID:32497418; 35071585; 34900869)we sought to determine if the diagnostic odyssey is longer for racial minorities compared to Caucasians. Methods: To test this hypothesis, we utilized the 2019 version of the Kids’ Inpatient Database (KID), developed by the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality (AHRQ). The HSCT sample was identified using ICD-10-PCS Procedure Codes for transfusion of hematopoietic/cord blood stem cells: Allogenic: 30243X3, 30243Y3, 30243X4, 30233X4, 30243Y2; Autologous: 30243Y0. A variable for pediatric genetic disease (PGD) was generated using 348 ICD-10-CM diagnostic codes corresponding to 283 pediatric genetic diseases for which the carrier frequency is greater than 1 in 500 in the general population or in an at-risk subpopulation (e.g., sickle cell anemia in AA). We controlled for malignant disease leading to HSCT using ICD-10-CM diagnostic codes to identify lymphomas, leukemias, myelodysplastic syndrome, myeloproliferative neoplasms, neuroblastomas, and brain tumors. Multiple linear regression was used to test if age of HSCT procedure was significantly associated with race, known non-malignant PGD, malignant disease, payer status, and location (rural vs. urban). Results: We identified 1,178 pediatric aged patients (age 20 and younger) who received HSCT in 2019 (Allogenic N=618; autologous N=560). The clinical characteristics of these patients are described in Table 1. The average age for Caucasian pediatric patients treated with HSCT is 6.8 years (82 months). Comparing PGD vs. all other diagnoses related to HSCT, patients with known PGD are transplanted on average 1.9 years (22 months) earlier than matched controls (P<0.001). This difference persists after controlling for race, disease severity, transplant type, Medicaid status, and rural health system location. African American and Asian pediatric patients are treated with HSCT on average 1.6 years (18 months) older than matched Caucasian controls (P=0.003 and 0.032, respectively). The effect of race persists even after controlling for thalassemias and sickle cell disease, associated with non-European ancestry. Conclusions: Age at transplant may be a useful surrogate for ongoing health disparities and to inform real-world research. African American and Asian ancestries are associated with HSCT at an older age, suggesting a prolonged diagnostic or therapeutic odyssey. This effect persists after controlling for factors such as non-malignant and malignant conditions, payer status, rural location, and genetic diseases that are over-represented in racial groups. More work is required to determine if this delay in treatment is due to differences in the spectrum of genetic diseases treated by HSCT in children of different ancestries, and if these delays in therapy may be associated with increased comorbidities and worse HSCT outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

A Clinical and Sociodemographic Risk Prediction Model Evaluating Adherence to Long-Term Care in Survivors of Childhood Leukemia

Background: Regular long-term follow-up care is important for surveillance and timely treatment of late effects after childhood leukemia therapy; however, structural barriers may disproportionately affect at-risk populations. Our objective was to evaluate factors associated with failure to utilize Long-Term Survivor (LTS) services following childhood leukemia treatment. Methods: We electronically extracted and manually curated electronic health records to identify childhood leukemia cases diagnosed between 2011 and 2014 at Texas Children's Cancer and Hematology Center. Individuals treated with a stem cell transplant, or those that transferred to an outside hospital, relapsed, or died within two years of end of treatment (EOT) were excluded. Address at the EOT was geocoded using ArcGIS to estimate travel time to the clinic and Area Deprivation Index, a composite measure of 17 neighborhood-level social determinants of health (SDOH). Multivariable logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association between clinical factors and attending LTS Clinic. LTS Clinic attendance was defined as at least one visit with an LTS provider at any time following EOT. Predictive performance of the model was evaluated using area under the receiver operating characteristic curve (AUC-ROC). Results: We identified 249 survivors of childhood leukemia that were eligible for LTS care in the designated time frame. Most were male (55%), non-Latino white (27%), Latino (57%), or non-Latino Black (10%) and were diagnosed at a median age of 5.7 years (range: 0.6-20). Overall, 41 survivors (16.5%) never attended LTS clinic. These included 15 survivors (6.0%) that were seen for initial disease follow-up after EOT but had no further contact with the hospital system beginning 2 years after EOT. In adjusted models, older age at EOT was associated with a higher likelihood of never attending LTS clinic (p<0.001). For example, survivors age 15 years and older at EOT were 7.4-times more likely to never attend LTS clinic (95% CI: 1.95-28.24). Additionally, compared with privately insured survivors, those with public insurance (OR=4.09, 95% CI: 1.67-9.99) and those that were uninsured (OR=4.68, 95% CI: 0.69-31.52) were more likely to never attend LTS clinic. LTS clinic attendance was largely comparable regardless of diagnosis, treatment exposures, sex, primary household language, and race/ethnicity, although Latinos were less likely to never attend an LTS visit compared with non-Latino whites (OR=0.36, 95% CI: 0.14-0.94). These observed associations were also independent of estimated travel time and neighborhood-level SDOH. Clinical and demographic factors provided reasonable predictive performance (AUC-ROC: 0.733, 95% CI: 0.655-0.821), e.g., categorizing survivors on their predicted probability of never attending LTS clinic based on observed clinical and demographic factors correctly identified 63.4% of survivors who never attend LTS clinic in the upper tertile of the risk prediction distribution. Conclusions: Texas has the highest rates of uninsured children in the United States, comprising 12.7% of all children and 17.5% of Latino children living in the state (2019 American Community Survey data). Moreover, Medicaid eligibility in Texas is significantly limited for adults between the ages of 18 and 65 years. In this study, both older age at EOT and public insurance or uninsured status at EOT were strongly predictive of no documented LTS care among survivors of childhood leukemia, suggesting health insurance is major limiting factor to accessing survivorship services in Texas. Limiting predictive factors to race/ethnicity, age at EOT and payer status at EOT provides reasonable prediction of leukemia survivor that do not engage in LTS care (AUC-ROC: 0.711). Validation of a simple risk prediction model using information readily available in the electronic medical record at EOT may inform targeted interventions to augment access to survivorship services in this vulnerable population.

DISP-15. TRENDS IN LASER INTERSTITIAL THERMAL THERAPY (LITT): HOW RACE AND SOCIOECONOMIC FACTORS IMPACT ACCESS

Abstract Introduction This study seeks to examine the trends of laser interstitial thermal therapy (LITT) access in the pre-and post-Medicaid expansion time periods; and more specifically, how racial and socioeconomic factors impact access. Methods The National Inpatient Sample (NIS) database was queried for all patients who received LITT from 2010 to 2019 for any indication. Age, gender, race, payer status, and median income by zip code were obtained and compared for the pre-Medicaid expansion (2010-2014), and post-Medicaid expansion (2015-2019) groups. Chi-square analysis was performed for categorical variables, and the student t-test was used to analyze continuous variables. Results The pre-Medicaid expansion (n = 915) and post-Medicaid (n = 3205) time periods were similar in that Whites were the overwhelming majority of LITT recipients (78.7% and 70.8%, p &amp;lt; 0.001). In 2010, all races had low rates of LITT, as would be expected with a new emerging treatment. Although the absolute value of the percentages seems similar, between 2013 and 2014, the proportion of Whites receiving LITT nearly doubled (from 45% to 75%); while all other groups had no significant increase in utilization. Utilization of LITT by Black Americans remained stable, 5.4% and 5.6% in the pre- and post-Medicaid expansion eras, while Hispanics and Others saw slight increases in utilization (8.8% to 10.1% and 7.1% to 13.4% respectively). Although Medicare and Medicaid usage increased over the years, private insurance remained the primary payer for LITT (53.8% and 49.3%, p 0.018). Lastly, patients within the highest income quartiles comprised over half of LITT procedures done in the study period (56.8% and 52.8%, p 0.029). Conclusion Despite nearly a decade and the effects of Medicaid expansion via the Affordable Care Act, LITT is still difficult to access for patients of color, Medicare and Medicaid users, and patients in low-income locales.

Lower socioeconomic status is associated with increased co-morbidity burden and independently associated with time to surgery, length of hospitalisation, and readmission rates of hip fracture patients.

The effect of socioeconomic status on hip fracture outcomes remains controversial. We examine the relationship between SES and patient comorbidity, care access, and clinical outcomes of surgically managed hip fracture patients. Using healthcare payor status as a surrogate for SES, patients operated for fragility hip fractures between 2013 and 2016 were dichotomised based on payor status, namely private healthcare (PRIV) versus subsidised healthcare (SUB). PRIV patients were compared with SUB patients in terms of demographic data, ASA scores, co-morbidity burden (Charlson comorbidity index, CCI), time to surgery, length of acute hospitalisation, and 90-day readmission rates. A total of 145 patients in group PRIV and 1146 patients in group SUB were included. SUB patients had a higher mean Charlson Co-morbidity Index (CCI) (p = 0.01), a longer length of hospitalisation (p = 0.001), an increased delay in surgery (p = 0.005), and higher 90-day readmission rates (p = 0.013). Lower SES (p = 0.01), older age (p = 0.01), higher CCI (p &lt; 0.01), and a higher American Society of Anaesthesiologists score (ASA) (p = 0.03) were predictive of time to surgery. Lower SES (p = 0.02) and higher CCI (p &lt; 0.001) were predictive of the length of hospitalisation. Lower SES (p = 0.04) and higher CCI (p &lt; 0.001) were predictive of 90-day readmission rates. Low SES is associated with higher CCI in surgically treated hip fracture patients. However, it is independently associated with slower access to surgery, a longer hospital stay, and higher readmission rates. Hence, lower SES, with its associated higher CCI and independent impact on surgical access and outcomes, can be considered a "double setback" in the management of fragility hip fractures.

Abstract 11887: Self-Pay Insurance Status is Associated With Failure of Medical Therapy in Patients With Acute Uncomplicated Type B Aortic Dissection

Introduction: Traditionally, acute uncomplicated type-B aortic dissections (auTBAD) are managed with best medical therapy. Recent literature has focused on identifying high-risk patients who might benefit from early endovascular repair based on dissection anatomy characteristics, but socioeconomic factors are less often considered despite relationships between disparities and vascular disease outcomes. Aim: To understand the presentation, management, follow-up, and outcomes among patients presenting with auTBAD, focusing on insurance status. Methods: In this single center, observational study, demographics, medication prescription patterns, follow-up, and outcomes of patients with auTBAD managed medically from 2013-2018 were analyzed. Patients with complicated, chronic, type-A dissection, PAU, or IMH were excluded. Area deprivation index (ADI) was determined from patient’s home addresses. Comparisons between age, ADI, prescription patterns, follow-up, and outcomes were made between groups based on payer status. Payer status was defined as insured or self-pay (i.e., no insurance). Results: 57 patients presented with auTBAD and were managed medically. 30% of patients were self-pay. Self-pay patients were from areas with higher deprivation indices (74 vs 62, p = 0.041), presented with higher blood pressures (138 vs. 118 mmHg, p = 0.006), and were on fewer home antihypertensives (0.29 vs 0.95, p = 0.030). Self-pay patients required more antihypertensives at discharge (3.6 vs 3.0, p = 0.049) and were less likely to follow-up (29% vs. 70%, p = 0.008). Self-pay patients had worse freedom from aortic intervention (p = 0.023), were more likely to represent urgently or emergently for repair (75% vs 0%, 0.033), and trended towards earlier time to intervention (8.5 months vs. 30 months, p = 0.060). Conclusions: Self-pay insurance was associated with worse hypertensive disease characteristics, follow-up patterns, and long-term outcomes in patients presenting with auTBAD managed with medical therapy. These findings suggest prohibitive compliance and surveillance trends in this cohort, which underscores the importance of considering patient factors, particularly payer status, when deciding between auTBAD treatment options.

Abstract 13882: Impact of Dementia on Inpatient Outcomes and Readmission Risks After Transcatheter Aortic Valve Replacement

Introduction: The prevalence of both aortic stenosis (AS) and dementia increases with age, but studies evaluating in-hospital outcomes and readmission risk after transcatheter aortic valve replacement (TAVR) in patients with dementia are scarce. Hypothesis: The presence of dementia is associated with higher rates of adverse in-hospital outcomes and readmissions following TAVR. Methods: Using the National Readmissions Database 2017-2018, we identified all admissions for TAVR in patients with AS and stratified them to those with and without dementia. We assessed delirium and falls in hospital using multivariable logistic regression, and 90-day readmissions using multivariable Cox proportional-hazard modeling, adjusted for demographics, comorbidities, hospital characteristics, primary payer, median income, and elective admission status. Results: Among 48,923 TAVR procedures, 2,192 (4.5%) were performed in patients with dementia. Patients with dementia experienced higher odds of delirium (adjusted odds ratio [aOR] 4.50, 95% confidence interval [CI] 3.35-6.05, p&lt;0.01) and fall in hospital (aOR 2.34, 95% CI 1.39-3.95, p&lt;0.01) during hospitalization for TAVR. Patients with dementia also experienced an increased hazard of 90-day readmission (adjusted hazard ratio 1.14, 95% CI 1.04-1.25, p&lt;0.01) (Figure 1). Causes of 90-day readmission were mostly non-cardiovascular. Conclusions: Patients with dementia undergoing TAVR suffered from increased odds of delirium and falls, with a higher hazard of 90-day readmission after discharge. These findings should be integrated into shared decision-making before elective TAVR.

Abstract 262: Race/ethnicity Is Associated With Mortality After Pediatric Cardiopulmonary Resuscitation: An Analysis Of The KIDs’ Inpatient Database

Introduction: Survival disparities in adult in-hospital cardiac arrest (IHCA) are well-described with decreased survival in Black patients. Pediatric literature from AHA’s GWTG—Resuscitation did not show this association, possibly due to differences in IHCA definitions and patient population. We aimed to investigate associations between outcomes after pediatric CPR and race/ethnicity and insurance payer status in a nationally representative database. We hypothesized non-White race/ethnicity, compared to white race, and public insurance, compared to private insurance, would be associated with lower rates of survival. Methods: Retrospective cohort study of subjects ≤18 years with CPR procedure codes in the 1997- 2019 editions of the Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID). We excluded subjects missing race/ethnicity, insurance payer or disposition and subjects with in-patient transfer as their disposition. We evaluated hypothesized associations with weighted mixed-effect logistic regression clustered by hospital. Hospital (size, teaching/non-teaching institution, rural/urban, region) and patient (age, KID cohort year, sex, insurance payer, complex chronic condition, median income quartile) confounders were considered fixed effects. Individual hospitals were treated as a random effect. Results: Our cohort included 27,332 children admitted to 3,353 centers. Univariable and multivariable modeling showed higher odds of in-hospital mortality for all non-White categories compared to white race: Black (aOR 1.20, 95% CI 1.08-1.34; p&lt;0.001), Hispanic (aOR 1.17, 95%CI 1.05-1.31; p=0.006), and other race/ethnicity (aOR 1.37, 95%CI 1.20-1.57; p&lt;0.001). There was no difference in mortality between those with public and private insurance. Conclusions: In contrast to previously published data, after risk- and reliability-adjustment of individual and hospital-level effects, children receiving CPR with non-White race/ethnicity had higher mortality odds. These findings suggest the presence of race/ethnicity-based disparities in pediatric IHCA mortality, the mechanisms of which should be explored.

Socioeconomic and Health-Related Factors Affecting Congestive Heart Failure Readmissions.

Congestive heart failure (CHF) readmissions are frequent and costly but preventable. The purpose of this study was to analyze socioeconomic and health-related factors of CHF readmissions by examining the relationship between 30-day readmissions of individuals with CHF and their payer status, race, ethnicity, primary language spoken, living arrangement, and comorbidities. This retrospective case-control study used secondary data from 450 CHF patients admitted to a not-for-profit Northern Virginia hospital from July 2014 to December 2017. Data were analyzed using χ 2 and logistic regression. Living arrangements and comorbid chronic renal failure (CRF) were statistically significant predictors of CHF readmissions; all other factors were nonsignificant. Patients who lived with family and those in assisted living facilities were less likely to be readmitted than those who lived alone (odds ratio [OR] = 0.2 and 0.5, respectively). Patients without CRF were less likely to be readmitted than those who had CRF (OR = 0.6). This study contributes data to inform community-based health programs tailored toward frequently readmitted individuals due to CHF exacerbation.

Hospitalizations at United States Children's Hospitals and Severity of Illness by Neighborhood Child Opportunity Index

To describe the association between neighborhood opportunity measured by the Child Opportunity Index 2.0 (COI) and patterns of hospital admissions and disease severity among children admitted to US pediatric hospitals. Retrospective, cross-sectional study of 773 743 encounters for children <18years of age admitted to US children's hospitals participating in the Pediatric Health Information System database 7/2020-12/2021. The proportion of children from each COI quintile was inversely related to the degree of neighborhood opportunity. The difference between the proportion of patients from Very Low COI and Very High COI ranged from +32.0% (type 2 diabetes mellitus with complications) to -14.1% (mood disorders). The most common principal diagnoses were acute bronchiolitis, respiratory failure/insufficiency, chemotherapy, and asthma. Of the 45 diagnoses which occurred in ≥0.5% of the cohort, 22, including type 2 diabetes mellitus, asthma, and sleep apnea had higher odds of occurring in lower COI tiers in multivariable analysis. Ten diagnoses, including mood disorders, neutropenia, and suicide and intentional self-inflicted injury had lower odds of occurring in the lower COI tiers. The proportion of patients needing critical care and who died increased, as neighborhood opportunity decreased. Pediatric hospital admission diagnoses and severity of illness are disproportionately distributed across the range of neighborhood opportunity, and these differences persist after adjustment for factors including race/ethnicity and payor status, suggesting that these patterns in admissions reflect disparities in neighborhood resources and differential access to care.

Prevalence of Substance use disorder among young adults hospitalized in the US hospital: A decade of change

IntroductionMental health disorders (MHD) and substance use disorders (SUD) lead to outstanding socioeconomic costs and increased hospital visits. However, very few studies have quantified this trend over time and across specific conditions. ​​Our study aims to investigate and compare the prevalence of MHDs and SUDs in hospitalizations between 2007 and 2017. MethodsWe used hospital records for 2007 and 2017 from the National Inpatient Sample (NIS) datasets to identify young adults (18–44 years) hospitalized with MHD and SUD. The prevalence of MHD in hospitalized patients in 2017 vs. 2007 was measured and compared. We generated a multivariable logistic regression analysis controlled for confounders, including age, sex, race, and payer status. We evaluated these outcomes using Odds Ratio (OR) and 95% Confidence Interval (CI). ResultsA total 10,353,890 patients were included in 2007, and 8,569,789 patients were included in 2017. The prevalence of drug abuse among hospitalized patients was 8.4% in 2017 vs. 6.2% in 2007. Prevalence increased in both genders (15.7% vs. 13.0% among male, 5.7% vs. 3.9% among females) in 2017 vs. 2007. All psychiatric disorders showed a higher prevalence in 2017 compared to 2007.When stratified by race, the prevalence of substance use disorder increased among all races except Black race between 2017 vs. 2007. On multivariable analysis, widespread drug abuse was significantly associated with hospital admissions in 2017 vs. 2007 (OR: 1.27, 95% CI: 1.20–1.34, p<0.001). These associations held across many substance abuse cases and mental health disorders except cocaine abuse (OR: 0.84, 95%CI: 0.76–0.93, p<0.001). ConclusionThere was a significant rise in substance use disorder and psychiatric disorder a decade later, from 2007, in hospitalized patients in the age group 18–44 years. The most increase was observed in amphetamine use disorder and anxiety disorder. Suicide and intentional self-inflicted injury increased in all races, with a maximum increase observed in Native Americans. Further studies evaluating the factors responsible for this upward trend would be beneficial.

Impact of Payer Status in Ventral Hernia Repair

Impact of Payer Status in Ventral Hernia Repair

Exploring the Association Between Paralytic Ileus and Endoscopic Retrograde Cholangiopancreatography Complications Using the National Inpatient Sample Database.

Introduction Paralytic ileus (PI) is often seen in critically ill hospitalized patients.Those with pancreaticobiliary diseases will require endoscopic retrograde cholangiopancreatography (ERCP) for management.Here, we will explore the association between patients with paralytic ileus who underwent ERCP and post-procedural complications, which has not been done before. Methods Patients who underwent ERCP between 2007 and 2017 in the National Inpatient Sample database were selected. Cases were matched 1:1 by age, gender, race, and the Elixhauser comorbidity index for patients with and without pre-procedural paralytic ileus. Primary outcomes were associations between paralytic ileus and length of stay, payor status, and average total charges. Secondary outcomes were associations between paralytic ileus and post-ERCP complications (infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage), and overall mortality. The Chi-squared analysis was used to compare categorical data, and the independent t-test was used for continuous data. Regression analysis was used to assess primary and secondary outcomes. Results Of 2,008,217 hospitalized patients from 2007 to 2017, 43,643 patients had paralytic ileus and 43,859 patients did not, before undergoing ERCP. There were no differences in age, gender, race, or the Elixhauser comorbidity index. The differences in the length of stay, payor status, and total charges were significant (p<0.001). Patients with paralytic ileus had increased risks of post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality (p<0.001). Conclusions Patients hospitalized with paralytic ileus who underwent ERCP had a longer length of stay, higher total charges, and were less compensable. They also had increased risks for post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality, which can be from critical illness and the systemic inflammatory response.

S1138 Malnutrition and Post-ERCP Complications: Nationwide Inpatient Sample Database Analysis

Introduction: Complications can arise from endoscopic retrograde cholangiopancreatography (ERCP). Few studies have studied the relationship between malnutrition and post-ERCP complications. One study identified malnutrition as a risk factor for post-ERCP cholangitis. Another study found malnourished patients had increased post-ERCP inpatient mortality and higher risks for sepsis, hemorrhage, and intestinal perforation. We seek to elucidate the relationship between malnutrition and post-ERCP complications. Methods: The National Inpatient Sample database was used to identify hospitalized patients over 18 years old who had an ERCP procedure between 2007 - 2017 using ICD-9 and ICD-10 codes. Patients were divided into two groups, those with and without malnutrition. Primary outcomes were length of stay, payor status, and total charges. Secondary outcomes were rates of post-ERCP pancreatitis, cholangitis, cholecystitis, infection, hemorrhage, perforation, and overall mortality. Patients were matched by age, race, sex, and Elixhauser comorbidity index. Chi-squared tests compared categorical data, independent t-tests compared continuous data, and multivariate analyses assessed primary outcomes. Results: Of 282,526 patients who met inclusion criteria, 141,285 had malnutrition. For both groups, the mean ages were 67 years old with 49% males, 69.7% White and 11.6% Black. The Elixhauser Comorbidity Index was 19.8 in the malnutrition group and 15.0 in the control group. Primary outcomes were significant for length of stay (13.9 days vs 7.9 days, p< 0.001), payor status (p< 0.001) with more patients in the malnutrition group having Medicare or Medicaid, and higher total charges ($139,346 vs $80,136, p< 0.001). Secondary outcomes were significant (p< 0.001) for the odds ratio of post-ERCP pancreatitis (OR 2.3), perforation (OR 2.4), cholangitis (OR 1.8), cholecystitis (OR 3.6), infection (OR 3.3), hemorrhage (OR 3.8), and mortality (OR 2.0). Conclusion: Malnutrition can be characterized as increased catabolic state versus decreased anabolic state. Catabolism, which involves the body expending energy, can occur in response to an acute stressor. Decreased anabolism can occur due to food insecurity or feeding issues. Malnutrition increases morbidity and mortality for patients undergoing procedures. Our data shows malnourished patients have increased risks for multiple post-ERCP complications. Patients’ nutritional statuses should be assessed and optimized prior to ERCP.