Rates Of Outpatient Follow-up Research Articles

Use of Telemedicine and Quality of Care Among Medicare Enrollees With Serious Mental Illness

During the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized. To compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use. In this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022. Practice-level use of telemedicine during the first year of the COVID-19 pandemic. The primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization. The pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were -0.4% (95% CI, -1.3% to 0.5%) and -0.1% (95% CI, -1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, -1.5% to 6.2%) and 2.8% (95% CI, -1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use. In this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.

Temporal trends of hypertrophic cardiomyopathy in Denmark: a nationwide retrospective cohort study

ObjectivesTo describe the population of patients diagnosed with hypertrophic cardiomyopathy (HCM) in Denmark and determine temporal trends in incidence and patient characteristics over time.DesignNationwide retrospective cohort study.SettingDanish nationwide administrative and...

Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care

BackgroundGuidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations. ObjectiveWe sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians. MethodsThis was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering. ResultsAmong 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99–12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08–3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51–0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62–0.91) or no insurance (OR 0.54; 95% CI 0.35–0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period. ConclusionsAn ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.

Evaluation of Dalbavancin Use on Clinical Outcomes, Cost-Savings, and Adherence at a Large Safety Net Hospital.

Dalbavancin is a second-generation lipoglycopeptide antibiotic with activity against Gram-positive organisms. Dalbavancin is Food and Drug Administration (FDA)-approved for acute bacterial skin and soft tissue infections (ABSSTIs). There is a lack of substantial data on dalbavancin in more invasive infections, particularly in high-risk populations (patients with intravenous drug use and unstable living conditions). In this retrospective observational study, we reviewed all patients that received at least one dose of dalbavancin in an inpatient or outpatient setting at Parkland Hospital from February of 2019 to August of 2021. The demographics, type of infection, and rationale for dalbavancin were collected at the baseline. Clinical failure was measured by an avoidance of emergency department (ED) visits or hospital readmission at 30, 60, and 90 days. A separate analysis was conducted to estimate hospital, rehabilitation, or nursing facility days saved based on the projected length of treatment. 40 patients were included, and the majority were uninsured (85%), experiencing homelessness (60%), or had intravenous drug use (IDU) (57.5%). Indications for use included ABSSTIs (45%), bloodstream infection (67.5%), osteomyelitis (40%), infective endocarditis (10%), and septic arthritis (10%). Clinical failure was observed in 5 of the 40 patients (12.5%). Nonadherence to medical recommendations, a lack of source control, and ongoing IDU increased the risk of failure. Dalbavancin saved a total of 566 days of inpatient, rehabilitation, and nursing facility stays. Dalbavancin is a reasonable alternative to the standard of care in an at-risk population, offering decreased lengths of stays and cost savings. The uses of second-generation lipoglycopeptides are desirable alternatives to traditional outpatient parenteral antibiotic therapies for patients who otherwise would not qualify or for patients who desire less hospital contact in light of the COVID-19 pandemic. IMPORTANCE This study contributes additional experience to the literature of dalbavancin use in off-label indications, particularly for patients who do not qualify for outpatient parenteral antimicrobial therapy. The majority of the patient population were people who inject drugs and the uninsured. There is difficulty in tracking outcomes in this patient population, given their outpatient follow-up rates; however, we were able to track emergency room visits and readmissions throughout the majority of the local metroplex. The clinical use of dalbavancin at our institution also increased in the midst of the COVID-19 pandemic in an effort to preserve hospital resources and limit health care exposure. In addition, we are able to provide institution-specific cost-saving data with the use of dalbavancin.

Green Pit Viper Envenomations in Bangkok: A Comparison of Follow-Up Compliance and Clinical Outcomes in Older and Younger Adults.

We compared older and younger adults envenomated by the green pit viper (GPV) with regard to the following: follow-up compliance, elapsed time between envenomation and emergency department (ED) visit, and clinical/treatment outcomes. This was a two-site retrospective cohort study. We searched hospital electronic medical databases between January 2011 and December 2021. Patients aged 15 and above were eligible if they had a history of snakebite and had at least two VCT and/or platelet count results in their medical records. After the search, 1550 medical records were reviewed and 760 cases were found to be eligible for analysis. In total, 205 cases (27.0%) were ≥60 years old. The median ages in the younger and older groups were 40 (26-51) and 68 (64-75) years, respectively. The median elapsed times from bite to the ED were 47 (30-118) vs. 69 (35-150) min (p-value = 0.001). Overall, 91.3% of all cases were managed as out-patient cases and were eligible for follow-up appointments. The rate of out-patient follow-up at 72 ± 12 h in the older patients was significantly higher (43.2%) than in the younger adult patients (32.4%) (p-value = 0.01). Regarding the clinical/treatment outcomes, the rates of coagulopathy, antivenom administration, and hospital admission were not statistically different between both groups.

Do parents vaccinated against COVID-19 protect their children from hospitalization due to COVID-19?

This study aimed to determine whether parental vaccination against coronavirus disease 2019 (COVID-19) prevents hospitalization of COVID-19-infected children. This study was based on data obtained from the records of pediatric patients that were followed up for virologically proven COVID-19 infection between August and October 2021, during which time the delta variant was dominant in Turkey and the children were isolating at home. There were 151 patients in the inpatient group and 218 in the outpatient group; the mean age was 172.5 and 145.5 months in the groups, respectively. The rates of obesity (22.5% and 6.4%, respectively, p < 0.001) and neurological-neurodevelopmental disorders (8.6% and 1.4%, respectively, p < 0.001) were significantly higher in the inpatient group than in the outpatient group. Of the outpatients' parents, 67.4% (n = 147) were fully vaccinated vs. 38.4% (n = 58) in the inpatient group. In all, 39.7% (n = 60) of the inpatients' parents were unvaccinated vs. 18.3% (n = 40) in the outpatient group. There was a significant correlation between the vaccination status and the patient groups (p < 0.001); it was determined that the COVID-19 infection would be mild in children if both parents were fully vaccinated. When both parents were fully vaccinated against COVID-19, the hospitalization rate decreased and the outpatient follow-up rate increased. Having both parents fully vaccinated against COVID-19 can indirectly protect their subsequently infected children from hospitalization and the long-term effects of infection. Nonetheless, more comprehensive research on delta and non-delta variants is needed.

S462 Impact of Esophageal Biopsies During Index Endoscopy for Food Bolus Impaction on Rates of Patient Outpatient Follow-Up and Recurrence of Food Bolus Impaction: A Retrospective Study

Introduction: Food bolus impaction (FBI) is a gastroenterological emergency requiring urgent upper endoscopy, of which up to half of cases may be due to eosinophilic esophagitis (EoE). EoE is defined by eosinophilic infiltration in the esophageal mucosa without secondary causes, which can lead to inflammatory and structural complications. Patients with EoE should have outpatient follow up as it can be effectively managed with proton pump inhibitors, swallowed topical steroids, and food elimination diets. This study aims to determine baseline rate of esophageal biopsy during index endoscopy for FBI, as recommended by American College of Gastroenterology clinical guidelines, and evaluate the impact of biopsies on rate of outpatient follow-up and repeat FBI presentations. Methods: This retrospective cohort chart review study evaluated patients over age 18 who presented with acute FBI at Dartmouth-Hitchcock Medical Center from 2015 to 2020. Patients with incidentally found food boluses and with non-food foreign body impactions were excluded. Simple count and chi-squared analyses were performed, with a p-value < 0.05 indicating significance. Results: 122 patients met inclusion criteria, with a mean age of 64 years old and 65% being male. Approximately half had a prior FBI though only 20% had a previous outpatient gastroenterology appointment. Baseline rate of esophageal biopsy during index endoscopy was 16%, of which 10% revealed a new diagnosis of EoE. After index endoscopy, 55% presented for outpatient follow-up and 51% underwent repeat endoscopy. 11% presented again to the emergency department for a recurrent FBI, with 31% of those patients having previously declined an outpatient visit. A greater percentage (65%) of patients with index biopsy completed an outpatient follow-up compared to those without a biopsy (53%) (p=0.32). There was minimal difference between those who had a biopsy and presented again with emergent FBI (15%) compared to those without a biopsy who re-presented (10%) (p=0.49). Conclusion: The baseline rate of esophageal biopsy during initial endoscopy was low, suggesting missed opportunities to diagnose EoE early. A greater number of index biopsy cases followed up in outpatient clinic, though was not statistically significant. Findings could be affected by low volume of index biopsies. Further research is needed to identify barriers to outpatient follow-up and treatment adherence for patients diagnosed with EoE on index biopsy.

Effect of Combining Conventional and Telehealth Methods on Managing Peritoneal Dialysis Patients: A Retrospective Single-Center Study.

Objective This study aimed to explore follow-up mode changes for peritoneal dialysis (PD) patients and their effects on PD quality during the COVID-19 pandemic. Methods A retrospective single-center study was conducted. All patients who received PD treatment at the Second Affiliated Hospital of Soochow University between January 2018 and March 2020 were enrolled in this study. Patient data during the first quarter of 2018 (Q1-2018), the first quarter of 2019 (Q1-2019), and the first quarter of 2020 (Q1-2020) were collected. Results No significant differences were observed for any serum examinations in different follow-up periods (P > 0.05). A significantly reduced outpatient follow-up rate was observed in Q1-2020 compared with Q1-2018 and Q1-2019 (71.6% Vs 78.9% Vs 84.7%, P < 0.001), accompanied by a significantly increased remote follow-up rate (28.4% Vs 21.1% Vs 15.3%, P < 0.001). Compared with Q1-2018 and Q1-2019, the hospitalization rate (27.7% Vs 30.9% Vs 15.7%, P < 0.001) and the incidence of peritonitis (0.162 Vs 0.186 Vs 0.08 per patient-year, P < 0.001) decreased significantly in Q1-2020. PD patients had a significant decline in the drop-out rate for Q1-2020 compared with Q1-2019 (4.4% Vs 7.3% Vs 2.2%, P < 0.001). No differences in the incidence of catheter-related infections were observed. No significant differences were observed for any peritoneal dialysis key performance indicators (KPIs) between outpatient follow-up and remote follow-up patients. Conclusion During the COVID-19 pandemic (Q1-2020), our center practiced more remote follow-up procedures in PD patients. The hospitalization rate and peritonitis incidence were significantly decreased compared with the same time in previous years. No statistical differences were observed in other KPIs for peritoneal dialysis. This study shows that telehealth methods are a reasonable alternative to in-person care in the care/management of PD patients.

An Epidemic Amidst a Pandemic: Musculoskeletal Firearm Injuries During the COVID-19 Pandemic.

The COVID-19 pandemic has substantially impacted the delivery of health care, both through direct care associated with COVID-19 and through more pervasive effects. Our goal was to evaluate whether the number of orthopaedic consultations for firearm injuries differed during the early months of the COVID-19 pandemic compared with the same period in prior years. We hypothesized that the initial months of the COVID-19 pandemic, compared with the same period in prior years, would have a higher number of orthopaedic consultations for firearm injuries and a lower rate of outpatient follow-up after consultations. A prospectively collected database of orthopaedic trauma consultations at a level-I trauma center was queried for firearm injuries. We compared the number of orthopaedic consultations for firearm injury during the initial months of the COVID-19 pandemic (March 23, 2020, to September 30, 2020, referred to as the pandemic group) with identical dates from 2017 to 2019 (referred to as the pre-pandemic group). Outpatient follow-up rates, ZIP codes (and associated Area Deprivation Index), and demographic data were compared between the pandemic group and the pre-pandemic group. During the entire study period, 552 orthopaedic consultations for firearm injuries were identified. There was a 63% increase in the daily mean number of firearm injury consultations in the pandemic group, to 1.01, compared with the pre-pandemic group, 0.62 (p < 0.001). There was no difference in the rate of outpatient follow-up: 66% for the pandemic group and 72% for the pre-pandemic group. There was no difference in the percentage of patients from the most socially deprived decile: 45.3% in the pandemic group and 49.5% in the pre-pandemic group. Patients presenting during the pandemic were more often uninsured (75.8%) relative to the pre-pandemic group (67.9%), with a lack of health insurance significantly decreasing the likelihood of outpatient follow-up (p < 0.01). Compared with the same period in prior years, there was a significant increase in the number of orthopaedic consultations for firearm injuries during the early months of the COVID-19 pandemic in our community. Patient race, socioeconomic status, and outpatient follow-up were similar between the pandemic group and the pre-pandemic group. There was a higher proportion of uninsured patients within the pandemic group and a lower rate of follow-up among those without insurance.

Association of Race and Ethnicity with the Frequency of Outpatient Glaucoma Care

This study examined 5815 adults with self-reported glaucoma in a representative US cohort. Non-Hispanic Black adults with glaucoma were significantly less likely to see an ophthalmologist or optometrist for glaucoma care, which may contribute to worse vision outcomes.

Outcomes from birth to 6months of publicly insured infants born to mothers with severe acute respiratory syndrome coronavirus 2 infection in the United States.

We evaluated inpatient management, transition to home, breastfeeding, growth, and clinical outcomes of infants born to mothers diagnosed with SARS-CoV-2 infection in pregnancy and followed in a Federally Qualified Health Center (FQHC), that serves a diverse and low-income patient population, from birth through 6months of life. Infants born between 4/3/20 and 7/26/20 at Prentice Women's Hospital with mothers who received prenatal care at Erie Family Health Center (Erie), the second largest FQHC in Illinois, and had confirmed SARS-CoV-2 during pregnancy were included. Data were abstracted from delivery hospital admission and outpatient follow-up appointments between 4/8/20 and 2/4/21. Thirty-three infants met inclusion criteria. Average gestational age was 38.9weeks (IQR 37.6-40.4), 3 (10%) were premature and 5 (15%) required NICU admission. Nearly all (97%) mothers expressed intent to breastfeed. Outpatient follow-up rates were similar to historical cohorts and 82% (23/28) of infants were vaccination compliant. Growth parameters showed normal distributions at all time points. At 6months, any and exclusive breast milk feeding rates were lower compared to historic cohorts (18 vs. 36%, p<0.05, 0 vs. 21%, p<0.01). Three infants (10%) received development-related referrals, one carried an underlying genetic diagnosis. Outpatient visits were predominantly face-to-face with telemedicine use comprising only 6% of visits (11/182). Longitudinal follow-up of 33 publicly insured infants born to mothers with SARS-CoV-2 infection in pregnancy followed in an FQHC showed high rates of follow-up and vaccination compliance, normal growth patterns and reassuring clinical status, and lower than expected rates of breastfeeding.

Factors Associated With Emergency Department Discharge, Outcomes and Follow-Up Rates of Stable Patients With Lower Gastrointestinal Bleeding.

BackgroundLower gastrointestinal bleeding (LGIB) is a common reason for hospitalization. However, recent data suggest low-risk patients may be safely evaluated as an outpatient. Here, we compare stable LGIB patients discharged from the emergency department (ED) with those admitted, determine factors associated with discharge and 30-day outcomes, and evaluate follow-up rates amongst the discharged cohort.MethodsA retrospective study of stable LGIB patients (heart rate < 100 beats/min, systolic blood pressure > 100 mm Hg and blood on rectal exam) who presented to the ED was conducted. Factors associated with discharge and rates of outpatient follow-up were determined in the discharged cohort. Therapeutic interventions and 30-day outcomes (including re-bleeding, re-admission and mortality rates) were compared between the admitted and discharged groups.ResultsNinety-seven stable LGIB patients were reviewed, of whom 38% were discharged and characteristics associated with discharge included age (P < 0.001), lack of aspirin (P < 0.002) and anticoagulant (P < 0.004) use, higher index hemoglobin (P < 0.001) and albumin (P < 0.001), lower blood urea nitrogen (P < 0.001) and creatinine (P = 0.008), lower Oakland score (P < 0.001), lower Charlson Comorbidity Index (P < 0.001) and lack of transfusion requirements (P < 0.001). There was no statistical difference in 30-day re-bleeding, re-admission or mortality rates between admitted and discharged patients. Discharged patients had a 46% outpatient follow-up rate.ConclusionsWhile early discharge in low-risk LGIB patients appears to be safe and associated with a decrease in length of stay, further studies are needed to guide timely and appropriate outpatient evaluation.

Follow-up and symptom persistence after esophageal food impaction.

Esophageal food impactions (EFI) are associated with esophageal pathology, most commonly eosinophilic esophagitis (EoE). Obtaining biopsies provides opportunity for diagnosis, which is important since treatment of EoE decreases the risk for future EFI. Outpatient follow-up rates remain suboptimal and outcomes of patients without timely follow-up are unknown. We aimed to identify the factors associated with pediatric subspecialty follow-up post-EFI and to determine the symptom burden in patients without follow-up. We performed a retrospective review of patients presenting with EFI at a tertiary children's hospital between 2010 and 2018. Patients without subspecialty follow-up within 1 year of EFI were included in a prospective telephone survey investigating the barriers to care, outcomes, and symptoms. Clinical characteristics were compared between groups. Multivariate analysis was used to control for multiple variables. There were 127 EFI identified in 123 individuals (73% male, mean age: 12.2years). Esophageal biopsies were collected in 76% of cases, and 49% of patients had follow-up. Individuals with follow-up were more likely (P ≤ 0.05) to have had biopsies. In a multivariate analysis, written recommendation for follow-up (Odds Ratio: 6.9 [2.4-19.5], P = 0.001) as well as atopic history and identified stricture were associated with a higher likelihood of follow-up. Those without follow-up had subsequent stricture (35%), dilation (44%), or EFI (39%), and 55% (12/22) described ongoing esophageal symptoms. Identification of treatable findings at time of EFI and ongoing symptom burden after EFI support an imperative for follow-up after EFI. Clear recommendations are a modifiable factor that may improve follow-up in this population.

Abstract P234: Stroke in Texas: Leveraging Population Level Data to Inform Public Health

Introduction: We studied variation in stroke rates, post-discharge health services, and outcomes across payors in Texas. Methods: Claims for 48,331 stroke patients in 2016 and hospital data covering 58,114 discharges were analyzed. Prevalence and incidence rates per region were reported as a variation from the state mean by payor type (Medicaid, Medicare and Commercial). Stroke overall, ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage are reported. Stroke outcomes are reported for the following measures: Discharges to rehabilitation, 30-Day Follow-Up with neurologist, death within 45 days Results: Among all payors, east Texas had the highest incidence and prevalence of ischemic stroke (Fig) but Northern Texas had the highest incidence of ICH among Medicaid and Commercial payors. Medicaid patients showed the greatest increases across ages and displayed a higher prevalence rate among those aged 40-64 than the 65+ group. Medicaid had a higher rate for each age group when compared to commercial. Within Medicaid and commercial, the 0-17 age had a very high rate of death from ischemic stroke (121/1000 and 83/1000, respectively), greater than any of the other age bands except over age 65; these high rates were not observed in ICH. Commercial and Medicaid patients had low rates of discharge to rehabilitation compared with Medicare (354/1000, 130/1000, 424/1000, respectively). Outpatient follow-up rates with a neurologist were low: Medicaid rates were very low compared to Commercial and Medicare (22/1000, 387/1000, 267/1000, respectively). Conclusion: Statewide review revealed dramatic variation in regional rates across all payors and ages. Graphic display and public reporting of statewide data on stroke through population level transparency can be leveraged to identify areas of risk, intervention strategies, and inform public health policy.

Buprenorphine for Opioid Use Disorder in the Emergency Department: A Retrospective Chart Review.

IntroductionEmergency care providers routinely treat patients with acute presentations and sequelae of opioid use disorder. An emergency physician and pharmacist implemented a protocol using buprenorphine for the treatment of patients with opioid withdrawal at an academic, Level I trauma center. We describe our experience regarding buprenorphine implementation in the emergency department (ED), characteristics of patients who received buprenorphine, and rates of outpatient follow-up.MethodsWe conducted a retrospective chart review of all patients in the ED for whom buprenorphine was administered to treat opioid withdrawal during an 18-month period from January 30, 2017–July 31, 2018. Data extraction of a priori-defined variables was recorded. We used descriptive statistics to characterize the cohort of patients.ResultsA total of 77 patients were included for analysis. Thirty-three patients (43%) who received buprenorphine did not present with the chief complaint of opioid withdrawal. Most patients (74%) who received buprenorphine last used heroin, and presented in moderate opioid withdrawal. One case of precipitated withdrawal occurred after buprenorphine administration. Twenty-three (30%) patients received outpatient follow-up.ConclusionsThis study underscores the safety of ED-initiated buprenorphine and that buprenorphine administration in the ED is feasible and effective.

Optimizing emergency department care transitions to outpatient settings: A systematic review and meta-analysis.

Suboptimal transitions from the emergency department (ED) to outpatient settings can result in poor care continuity, and subsequently higher costs to the healthcare system. We aimed to systematically review care transition interventions (CTIs) for adult patients to understand how effective ED-based CTIs are in reducing return visits to the ED and increasing follow-up visits with primary care physicians. We searched multiple databases and identified eligible published RCTs of ED-based CTIs affecting outpatient follow-up rates, ED readmission and hospital admission. Two independent authors reviewed titles and abstracts for potential inclusion and selected studies for full review. Study quality was assessed using the Cochrane risk-of-bias tool. ED-based CTIs were classified using a care continuity framework. Our search generated 28,807 articles; 112 were selected for full-text review. Data were abstracted from 42 articles that met inclusion criteria. Pooling data from 20 studies (n=8178 patients) found a relative increase in outpatient follow-up with ED-based CTIs compared to routine care (odds ratio 1.79, 95% confidence interval [CI] 1.43, 2.24). However, ED-based CTIs (20 studies, n=8048 patients) had no significant effect on ED readmissions (odds ratio 1.02, 95% CI 0.87, 1.20]) or hospital admission after ED discharge (13 studies, n=5742 patients) (odds ratio 0.99, 95% CI 0.86, 1.14) when compared to routine care. Twenty-two studies encompassed CTIs supporting all three functions of care continuity (information, communication and coordination). ED-based CTIs do not appear to reduce ED revisit or hospital admission after ED discharge but are effective in increasing follow-up.

Readmission Rates for Heart Failure in a Safety-Net Hospital

Background Despite ongoing efforts, heart failure hospitalization (HFH) rates remain high. The underserved population may be at higher risk for readmission given limited access to health care professionals, advanced device-based therapies, and newer medications. The goal of the current study was to determine HFH rates in an urban Safety-Net hospital and to identify clinical and non-clinical factors that may influence these rates. Methods All patients g 18 years of age admitted to the Coronary Care Unit from March 2017 to February 2018 at Los Angeles County USC Medical Center were indexed in a database. Demographics, insurance status, history of drug use, ejection fraction (EF), etiology of heart failure, treatment received, and length of hospital stay were collected. All-cause and 30-day HFH rates were determined. Results During the study period, 188 patients were identified. Mean age was 58±14 years, 69% were male, 15% had preserved EF, and 35% had an ischemic cardiomyopathy. The prevalence of active tobacco/alcohol use was 42%. Active use of methamphetamines, heroin, cocaine, and/or cannabis was present in 18%. HFH at 30 days for the entire cohort was 17%. Length of hospital stay was 4.2±5.1days. Following the index hospitalization, only 45% of patients returned for a scheduled follow-up outpatient visit. On univariate analysis, current drug use, current alcohol/smoking, and homelessness were associated with an increased HFH rate within 30 days. On multivariate analysis, homelessness was the only independent risk factor associated with HFH (p=0.049). Conclusions Homeless individuals have a significantly increased risk for heart failure hospitalization. Additional interventions focused on improving post-discharge outpatient follow-up rates, targeting continued drug use, and facilitating adequate housing are required in the underserved population.

A Multidisciplinary Intervention to Improve Care for High-Risk COPD Patients.

Chronic obstructive pulmonary disease (COPD) exacerbations contribute to both costs and patient morbidity. The authors designed a quality project to improve care for high-risk COPD patients admitted with an exacerbation. An electronic medical record report was used to target admitted high-risk COPD patients for an intervention that included pulmonary and respiratory therapy consults, post-discharge phone calls from a patient navigator, referrals to palliative services when appropriate, and bedside delivery of medications. The control population was a similar group of patients at a community partner hospital who received usual care. In all, 157 unique patients were enrolled over 16 months; referrals to palliative care services increased and rates of outpatient follow-up improved. There was no difference in readmissions or emergency department visits between the 2 groups. Better coordination of outpatient care and attention to psychosocial burdens were identified as possible targets for future interventions.

Alcohol misuse and outpatient follow-up after hospital discharge: a retrospective cohort study

PurposePatients with alcohol misuse are less likely to receive preventive health services but more likely to utilize emergency health services. However, the association between alcohol misuse and outpatient follow-up after hospitalization is unknown and may depend on whether a patient experiences a critical illness. We sought to determine whether alcohol misuse was associated with lower rates of outpatient follow-up after hospital discharge and whether the magnitude of this association differed in patients who experienced a critical illness.Materials and methodsThis was a retrospective cohort study using administrative data from an urban safety net hospital. Patients were included if they were admitted between 2011 and 2015, were between the ages of 18 and 89, resided within the safety net county, were discharged home, and were at moderate to high risk for hospital readmission within the subsequent 30 days. Alcohol misuse was identified using a combination of ICD-9 codes and response to a single screening question. The primary outcome was a combined measure of follow-up with a primary care physician or specialist provider in the 30 days following hospital discharge. Multivariable logistic regression was used to adjust for factors known to be associated with healthcare utilization.ResultsOverall, 17,575 patients were included in the analysis; 4984 (28%) had alcohol misuse. In the 30 days following hospital discharge, 46% of patients saw any outpatient provider. In an unadjusted analysis, the association between alcohol misuse and attending any outpatient follow-up was dependent on whether patients had a critical illness (p value < 0.0001) with the highest rates of follow-up in survivors of critical illness without alcohol misuse (53%, 95% CI 51%, 55%) followed by patients without alcohol misuse or critical illness (49%; 95% CI 48%, 50%), patients with alcohol misuse without critical illness (38%; 95% CI 36%, 39%), and patients with alcohol misuse and a critical illness (37%; 95% CI 35%, 40%). Adjusting for factors associated with healthcare utilization, these findings were modestly attenuated but unchanged.ConclusionsPatients with alcohol misuse who are at moderate to high risk for hospital readmission may benefit from targeted interventions to increase rates of outpatient follow-up after hospital discharge.

1301. Evaluation of the Rates of HIV Post-Exposure Prophylaxis Completion After the Implementation of an Automated Referral System in the Emergency Department

BackgroundA 28-day regimen of Post-Exposure Prophylaxis (PEP) administered within 72 hour significantly reduces HIV infection, for both occupational and nonoccupational exposures (NOE); however, adherence to PEP for NOE has been reported to have poor rates of completion.1 To optimize PEP referrals from our ED to our clinics, we implemented an automated referral system to maximize PEP completion and link patients to outpatient care and HIV pre-exposure prophylaxis (PrEP), if appropriate.MethodsIn our ED, PEP patients receive a starter kit from an automated medication dispensing system. Starting in March 2017, a daily automated report of patients who received a starter kit in the ED was generated and emailed to patient navigators who would contact patients and offer follow-up appointments. Our main objective was to describe the rate of outpatient follow-up of patients initiated on PEP for NOE from March 2017 to March 2018, as well as patient demographics and linkage to PrEP.ResultsOut of 128 patients seen in the ED for PEP, 30% (38) were for NOE. Of these, 68% were female, with a median age of 27 years old (range: 14–59). Nearly half had no insurance (45%). The majority (84%) reported sexual intercourse or sexual assault as the exposure. Most patients were contacted for follow-up (76%) and half (48%) had a follow-up appointment. Patients who presented to the ED >24 hours after exposure were less likely to complete a follow-up (35% vs. 75%, P = 0.035), as were uninsured patients (24% vs. 57%, P = 0.052). From 38 patients, 13 (34%) qualified for PrEP, eight (62%) followed as outpatients and one (8%) was started on PrEP.ConclusionThe automated system ensured that half our PEP patients were seen by an outpatient provider, increasing their likelihood of finishing the 28 days of PEP. Patients presenting late to the ED and uninsured patients were less likely to follow-up. Further research is needed to identify interventions to improve follow-up. Finally, transition to PrEP was low and additional interventions should be explored to improve this process. Reference1. Kahn JO, Martin JN, Roland ME, et al. Feasibility of postexposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injection drug use exposure: the San Francisco PEP Study. J Infect Dis 183(5):707–714.Disclosures All authors: No reported disclosures.