Reduce Emergency Department Visits Research Articles

Medication selection, health services outcomes, and cost trajectories for Medicaid beneficiaries with infantile spasms

ObjectiveThere are three recommended first-line treatments for infantile spasms, adrenocorticotropic hormone (ACTH), oral corticosteroids, and vigabatrin, though non-standard treatments such as topiramate are sometimes selected. Is it uncertain how treatment selection influences health services outcomes. MethodsWe conducted a retrospective cohort study of Medicaid beneficiaries newly diagnosed with infantile spasms from 2009–2010. We included infants with a new diagnosis of infantile spasms between age 2–9 months who filled ACTH (reference), prednisolone, vigabatrin, or topiramate prescriptions. Multivariable Cox proportional hazards regression compared time to first emergency department (ED) visit or hospitalization across treatment groups during 2 years of follow-up. Monthly costs for each treatment were examined in 6-month intervals and compared in a multivariable generalized linear model. ResultsAmong 256 children with infantile spasms, 116 received ACTH, 62 prednisolone, 15 vigabatrin, and 63 topiramate. The rate of ED visit or hospitalization per person-year did not differ significantly for prednisolone (0.9 [95 % CI 0.7–1.2]; adjusted hazard ratio [aHR] 0.84, 95 % CI 0.57–1.24), vigabatrin (0.8 [95 % CI 0.4–1.5]; aHR 0.91, 95% CI 0.45–1.84), or topiramate (1.7 [95 % CI 1.3–2.3]; aHR 1.15, 95 % CI 0.80–1.65), when compared to ACTH (1.1 [95 % CI 0.9–1.3]). The median payment for ACTH was $96,406 (interquartile range 70,742–138,476) during the first 6 months. The adjusted mean total payment in the first 6 months was 73% lower for prednisolone (95% CI −82, −61), 69% lower for vigabatrin (95% CI −84, −40), and 73% lower for topiramate (95% CI −82, −59). However, in subsequent 6-month intervals, costs associated with ACTH were not significantly different compared to other treatments. SignificanceCompared to other treatments for infantile spasms, use of ACTH was associated with greater cost in the first 6 months of treatment, but not with reduced ED visits or hospitalizations. The cost effectiveness of ACTH depends on its relative clinical efficacy, and merits additional research.

Impact of Coronavirus Disease 2019 Pandemic on Crowding: A Call to Action for Effective Solutions to "Access Block".

IntroductionHealthcare patterns change during disease outbreaks and pandemics. Identification of modified patterns is important for future preparedness and response. Emergency department (ED) crowding can occur because of the volume of patients waiting to be seen, which results in delays in patient assessment or treatment and impediments to leaving the ED once treatment is complete. Therefore, ED crowding has become a growing problem worldwide and represents a serious barrier to healthcare operations.MethodsThis observational study was based on a retrospective review of the epidemiologic and clinical records of patients who presented to the Foundation IRCCS Policlinic San Matteo in Pavia, Italy, during the coronavirus disease 2019 (COVID-19) outbreak (February 21–May 1, 2020, pandemic group). The methods involved an estimation of the changes in epidemiologic and clinical data from the annual baseline data after the start of the COVID-19 pandemic.ResultsWe identified reduced ED visits (180 per day in the control period vs 96 per day in the pandemic period; P < 0.001) during the COVID-19 pandemic, irrespective of age and gender, especially for low-acuity conditions. However, patients who did present to the ED were more likely to be hemodynamically unstable, exhibit abnormal vital signs, and more frequently required high-intensity care and hospitalization. During the pandemic, ED crowding dramatically increased primarily because of an increased number of visits by patients with high-acuity conditions, changes in patient management that prolonged length of stay, and increased rates of boarding, which led to the inability of patients to gain access to appropriate hospital beds within a reasonable amount of time. During the pandemic, all crowding output indices increased, especially the rates of boarding (36% vs 57%; P < 0.001), “access block” (24% vs 47%; P < 0.001), mean boarding time (640 vs 1,150 minutes [min]; P 0.001), mean “access block” time (718 vs 1,223 min; P < 0.001), and “access block” total time (650,379 vs 1,359,172 min; P < 0.001).ConclusionCrowding in the ED during the COVID-19 pandemic was due to the inability to access hospital beds. Therefore, solutions to this lack of access are required to prevent a recurrence of crowding due to a new viral wave or epidemic.

Palliative home care and emergency department visits in the last 30 and 90 days of life: a retrospective cohort study of patients with cancer

ObjectivesEvaluate the association of specialist palliative home care (HC) on emergency department (ED) visits in the 30 and 90 days prior to death.MethodsThis retrospective cohort study using administrative data identified...

Do Acupuncture Services Reduce Subsequent Utilization of Opioids and Surgical Interventions Compared to Noninvasive Therapies among Patients with Pain Conditions?

ObjectiveTo compare prescribed opioid use and invasive surgical interventions between patients using acupuncture and those using non-steroidal anti-inflammatory drugs (NSAIDs)/physical therapy (PT).DesignRetrospective observational study of administrative claims.SettingLarge commercial insurance plan.Subjects52 346 each treated with either acupuncture or NSAIDs/PT.MethodsUsers of acupuncture and NSAIDs/PT were identified from January 1, 2014, to December 31, 2017. The first date of each service was defined as the index date. Acupuncture patients were 1:1 propensity score matched to the NSAIDs/PT group on baseline characteristics. Outcomes included opioid use, subsequent invasive surgical procedures, healthcare utilization such as hospitalizations or emergency department (ED) visits, and costs. These were assessed in the 12-month period before index date (baseline) and 12-month period following index date (follow-up) using difference-in-difference (DID) analysis. Results for opioid use were stratified by those with and without baseline opioid use.ResultsThe acupuncture group had fewer patients initiating opioids post-index both among those with (49.2% vs 56.5%, P < .001) and without (15.9% vs 22.6%, P < .001) baseline opioid use. There was a small increase in invasive surgical procedures with acupuncture (3.1% vs 2.8%, P = .006). A reduction in ED visits was observed with acupuncture (DID −4.6% for all-cause; −3.3% for pain-related, all P < .001). Acupuncture was associated with higher total medical and pharmacy costs (DID +$1331 per patient, P = .006).ConclusionsAcupuncture showed a modest effect in reducing opioid use and ED visits. More research on acupuncture’s place in emergency care, pain relief, and comparison to other types of non-opioid treatment is needed.

The Efficacy of Bamlanivimab in Reducing Emergency Department Visits and Hospitalizations in a Real-world Setting.

Bamlanivimab, a monoclonal antibody targeting the spike protein of severe acute respiratory syndrome coronavirus 2, is available for ambulatory treatment of coronavirus disease 2019 (COVID-19). This real-world study confirms the efficacy of bamlanivimab in reducing hospital admissions and emergency department visits among high-risk outpatients with mild to moderate COVID-19 illness and reveals a trend toward improved mortality.

PBI11 Economic Impact of Utilizing Eptacog Beta for the on-Demand Treatment of Bleeding Events Among Hemophilia Patients with Inhibitors

A mainstay of treatment in haemophilia patients with inhibitors (PWI) is recombinant Factor VIIa (rFVIIa) bypassing agent. The FDA recently approved a new rFVIIa (eptacog beta (EB)) variant that may reduce bypassing agent use for on-demand treatment of bleeding events (BEs). The aim of this study was to quantify the clinical and economic value associated with use of EB vs Coagulation rFVIIa eptacog alfa (EA), for on-demand treatment of bleeding episodes (BE) occurring in PWI. A decision analytic model was developed to compare the utilization, clinical outcomes and costs of EA and EB among hemophilia PWI utilizing on-demand treatment of BEs over the course of one year. Treatment regimens of rFVIIa were based on prescribing information. Clinical efficacy was informed by clinical trial data. Epidemiology and costs for emergency department (ED) visits, hospital admissions, and intravenous-access (IV-access) complications were informed by literature. Drug costs were 2020 wholesale acquisition costs. In a cohort of 1 million insured males, 5 PWI annually receive on-demand treatment for 54 mild/moderate BEs. If all PWI switch from EA to EB 75μg/kg or to EB 225μg/kg for on-demand use, a health plan would reduce the total costs from $3.7million to $1.7million (54%) or to $2.3million (40%), respectively. The majority of the savings are driven by reduced drug costs of $1.7million (85%) or $1.1million (76%), from the lower acquisition costs of EB and reduced consumption by 48% or 33%, with EB 75μg/kg or 225μg/kg, respectively. The remaining savings were from reduced ED visits, hospitalizations and IV-access complications. The model suggests use of EB may reduce cost of rFVIIa from lower acquisition costs and fewer vials consumed. Additionally, fewer cases of re-bleeding or unresolved bleeding and fewer IV-accesses with EB therapy results in lower costs of ED visits, hospitalizations and IV-access complications.

Economic and utilization outcomes of medication management at a large Medicaid plan with disease management pharmacists using a novel artificial intelligence platform from 2018 to 2019: a retrospective observational study using regression methods.

BACKGROUND: Medication therapy management (MTM) and comprehensive medication management (CMM) have been practiced by clinical pharmacists as a predominantly manual activity with interventions documented in a record-keeping system. Program evaluations, largely based on estimations of projected savings and utilization reductions, have not accurately predicted actual claims and utilization changes, leading many to doubt the efficacy of medication management. OBJECTIVE: To assess the impact on actual medical claims of a novel artificial intelligence (AI) platform that identifies members and provides decision support to clinicians in performing telephonic interventions similar to MTM and CMM with high-risk Medicaid members. METHODS: This retrospective observational study used mixed-effects regression models that flexibly account for general trends in cost, as measured by actual claims, to identify the amount of savings and associated impact. To study the economics, total cost of care (TCoC), defined as all medication costs plus all noncapitated medical costs, was evaluated. Utilization was evaluated through the number of emergency department (ED) visits, hospital admissions, bed days, and readmissions. The study included 2,150 predominantly middle-aged (aged 40-64 years) Medicaid members with an average of 10 medications for chronic conditions among an average of 25 total medications. The analysis considered cost and utilization data from August 2017 through April 2019. Interventions occurred between January 2018 and February 2019. RESULTS: Statistically significant correlations were found between receiving interventions and decreased costs and utilization. The economic study found a 19.3% reduction in the TCoC (P < 0.001) that, applied to a preintervention monthly cost of $2,872, yielded a savings of $554 per member per month (PMPM). Medication costs showed a 17.4% reduction (P < 0.001), which, when applied to preintervention cost of $1,110, yielded a savings of $192 PMPM. The utilization study found a 15.1% reduction in ED visits (P = 0.002), a 9.4% reduction in hospital admissions (P = 0.008), and a 10.2% reduction in bed days (P = 0.01). Return on investment is 12.4:1 based on TCoC savings and program costs. CONCLUSIONS: This study evaluated the CMM-Wrap program, which used an advanced AI platform integrated with health plan data, clinical pharmacists trained in disease management, telephonic patient engagement, and closed-loop provider coordination. The results correlate cost and utilization savings with the program. The TCoC savings of $554 PMPM translates to approximately $1.2M a month and more than $14M annually for the 2,150 members in the study. We believe Medicaid and Medicare payment of AI enhanced telephonic CMM services would substantially decrease government health care expenditures, whereas improving health program expansion to Medicaid members with similar risks could save the Health Plan $109M annually. For instance, we estimate that California's Medicaid (Medi-Cal) program could save more than $1B annually by applying the program's observed impact to a similar high-risk cohort (about 1.6%) of Medi-Cal members. Additionally, benefits will accrue to nonmanaged health plans based on the savings themselves. DISCLOSURES: There was no external funding for this study. The program itself was funded by Inland Empire Health Plan. The retrospective study was a collaboration of the 3 partners (Surveyor Health, Inland Empire Health Plan, and Preveon Health) each of which funded its additional costs of preparing the study. Kessler, Mebine, E. Von Schweber, and L. Von Schweber are employed by Surveyor Health. McConnell and Jai are employed by Inland Empire Health Plan. Nguyen, Kiroyan, and Ho are employed by Preveon Health. Desai reports fees from Surveyor Health for work on this study. E. Von Schweber and L. Von Schweber have 2 patents licensed to Surveyor Health: Unified Evaluation, Presentation and Modification of Healthcare Regimens Method and Apparatus for Information Surveying.

A population-based analysis of the impact of the COVID-19 pandemic on common abdominal and gynecological emergency department visits.

BACKGROUND:Reduced use of the emergency department during the COVID-19 pandemic may result in increased disease acuity when patients do seek health care services. We sought to evaluate emergency department visits for common abdominal and gynecologic conditions before and at the beginning of the pandemic to determine whether changes in emergency department attendance had serious consequences for patients.METHODS:We conducted a population-based analysis using administrative data to evaluate the weekly rate of emergency department visits pre-COVID-19 (Jan. 1–Mar. 10, 2020) and during the beginning of the COVID-19 pandemic (Mar. 11–June 30, 2020), compared with a historical control period (Jan. 1–July 1, 2019). All residents of Ontario, Canada, presenting to the emergency department with appendicitis, cholecystitis, ectopic pregnancy or miscarriage were included. We evaluated weekly incidence rate ratios (IRRs) of emergency department visits, management strategies and clinical outcomes.RESULTS:Across all study periods, 39 691 emergency department visits met inclusion criteria (40.2 % appendicitis, 32.1% miscarriage, 21.3% cholecystitis, 6.4% ectopic pregnancy). Baseline characteristics of patients presenting to the emergency department did not vary across study periods. After an initial reduction in emergency department visits, presentations for cholecystitis and ectopic pregnancy quickly returned to expected levels. However, presentations for appendicitis and miscarriage showed sustained reductions (IRR 0.61–0.80), with 1087 and 984 fewer visits, respectively, after the start of the pandemic, relative to 2019. Management strategies, complications and mortality rates were similar across study periods for all conditions.INTERPRETATION:Although our study showed evidence of emergency department avoidance in Ontario during the first wave of the COVID-19 pandemic, no adverse consequences were evident. Emergency care and outcomes for patients were similar before and during the pandemic.

Analysis of reasons for emergency department (ED) visits and resulting hospital admissions in breast cancer patients: A retrospective study from rural cancer center in Maine.

e18682 Background: Reducing ED visits in patients with cancer is cost saving and is particularly relevant during the COVID pandemic. Methods: We analyzed the number of ED visits occurred in our breast cancer population between July 1 2019 and August 31 2020 including demographics, stage distribution, treatment type within the month of ED visit, reason, time of the day, day of the week the visit occurred. Results: A total of 101 patients had 162 visits. 38 (38%) had more than 1 ED visit. Majority (36%) had stage 4 disease at the time of ED visit. The top 5 reasons for ED visits were fall and injury (N=30), GI (N=24), cardiac (N=17), respiratory symptoms (N=14) and cancer related pain (N=11). The median age in patients with ED visit due to fall injury/pain was 75 and non-fall injury/pain was 55 years. The most common reasons for chemotherapy induced ED visits were GI related (N=8) and Neutropenic fever (N=7). Cyclophosphamide/doxorubicin was the common regimen associated with neutropenic fever. A total of 72 (44%) visits resulted in hospital admissions. Most common symptom categories requiring hospital admissions were cardiac (82.3%), sepsis/cellulitis (81.8%), respiratory (64%), cancer related pain (54.5%) and GI (50%). Most were on endocrine therapy at the time of their visit (N= 59) and 31 were on no treatment at all. Falls were unrelated to disease or treatment and occurred in patients above age 70. Visits occurred during working hours from 6AM to 5PM, with peak incidence on Mondays and Fridays. Conclusions: Reducing ED visit in cancer patients is a worthwhile endeavor particularly in the context of the COVID pandemic. The main reason for ED visits were falls and injuries that were unrelated to disease or treatment in breast cancer patients. As a result, we are implementing systematic physical therapy assessment for our breast cancer population over age of 60 at our cancer center and call us first campaign, to get an opportunity to intervene prior to going to the ED as majority of the ED visits occurred during working hours.[Table: see text]

Immune Checkpoint Inhibitor-Induced Hypophysitis in Renal Cell Carcinoma: Two Contrasting Case Presentations

Background: Increasing use of immune checkpoint inhibitor (ICI) therapy for malignancy has led to rising incidence of ICI-mediated endocrinopathies. We describe two varying cases of patients with renal cell carcinoma (RCC) who presented with ICI-mediated hypophysitis. Cases: Patient A: A 72 year old female with RCC (T1bN0M0) diagnosed after an incidental renal mass was found on CT scan following a motor vehicle accident. After nephrectomy, she received 5 cycles of nivolumab (6/2019 to 10/2019). One month later, she presented in severe DKA and was diagnosed with ICI-mediated diabetes (low c-peptide, negative autoantibodies). ICI therapy was stopped. In 4/2020, she experienced a drastic reduction in her insulin requirement (~30 units/day of basal/bolus insulin to ~6 units/day of basal insulin only). She had a primary care visit for fatigue, nausea, and anorexia. Biochemical evaluation showed hyponatremia, normokalemia, normoglycemia, and no acid-base disorder. One week later, she presented to the emergency department (ED) with worsening symptoms. She was hypotensive (94/56 mmHg), hyponatremic (129 mmol/L), normokalemic, and azotemic. Cosyntropin stimulation test (CST) showed an inappropriate response [ACTH <5 pg/ml; cortisol response of 0.4 to 8.1 µg/dl]. Brain MRI showed a partially empty sella. She was diagnosed with secondary adrenal insufficiency (AI) due to hypophysitis and started on steroid replacement. A repeat CST after 3 months did not show HPA axis recovery. Her presentation is unique because she developed secondary AI six months after nivolumab therapy. Patient B: A 43 year old female with RCC (T4N1M1) who received 4-cycles of ipilimumab and nivolumab (11/2019 to 1/2020). One month later, she presented to the ED with hypotension, anorexia, and fatigue. Biochemical evaluation showed severe DKA. She was diagnosed with ICI-mediated diabetes (low c-peptide, negative autoantibodies) and started on basal/bolus insulin. Her ICI-therapy was stopped. One month later, she was readmitted for hypotension and severe headaches and found to have hyponatremia (131 mmol/L), normokalemia, hyperprolactinemia (29 ng/ml), cortisol 4.5 µg/dl (previous random cortisol a month earlier was 33 µg/dl). Pituitary gland was normal on MRI. She was presumed to have secondary AI due to hypophysitis and started on steroid replacement. A CST performed after 3 months showed ACTH <5 pg/ml and cortisol response of 3.5 to 4.5 µg/dl. Her case was a usual presentation of ICI-mediated secondary AI as it occurred within 1-2 months of stopping ICI therapy. Conclusion: As we continue to learn about ICI-mediated endocrinopathies, it is imperative to document the variation in timing of presentation. ICI-mediated hypophysitis can present at any time after the initiation of therapy. Given this variation, there is need for routine screening and early treatment of hypophysitis to reduce ED visits and readmission rates.

Non-COVID-19 patients in times of pandemic: Emergency department visits, hospitalizations and cause-specific mortality in Northern Italy.

The COVID-19 pandemic forced healthcare services organization to adjust to mutating healthcare needs. Not exhaustive data are available on the consequences of this on non-COVID-19 patients. The aim of this study was to assess the impact of the pandemic on non-COVID-19 patients living in a one-million inhabitants’ area in Northern Italy (Bologna Metropolitan Area-BMA), analyzing time trends of Emergency Department (ED) visits, hospitalizations and mortality. We conducted a retrospective observational study using data extracted from BMA healthcare informative systems. Weekly trends of ED visits, hospitalizations, in- and out-of-hospital, all-cause and cause-specific mortality between December 1st, 2019 to May 31st, 2020, were compared with those of the same period of the previous year. Non-COVID-19 ED visits and hospitalizations showed a stable trend until the first Italian case of COVID-19 has been recorded, on February 19th, 2020, when they dropped simultaneously. The reduction of ED visits was observed in all age groups and across all severity and diagnosis groups. In the lockdown period a significant increase was found in overall out-of-hospital mortality (43.2%) and cause-specific out-of-hospital mortality related to neoplasms (76.7%), endocrine, nutritional and metabolic (79.5%) as well as cardiovascular (32.7%) diseases. The pandemic caused a sudden drop of ED visits and hospitalizations of non-COVID-19 patients during the lockdown period, and a concurrent increase in out-of-hospital mortality mainly driven by deaths for neoplasms, cardiovascular and endocrine diseases. As recurrencies of the COVID-19 pandemic are underway, the scenario described in this study might be useful to understand both the population reaction and the healthcare system response at the early phases of the pandemic in terms of reduced demand of care and systems capability in intercepting it.

Determinants of asthma-related emergency department return visits in adults: A population-based study

RATIONALE: Emergency department (ED) return-visit rates provide a measure of the quality of acute asthma care. OBJECTIVES: We sought to assess the impact of patient and site characteristics, including asthma management strategies, on return visits within 72 hours, prior to implementation of a standardized adult ED asthma care pathway in EDs throughout Ontario, Canada. METHODS: This population-based cohort study utilized comprehensive administrative health data from the Institute for Clinical Evaluative Sciences for adults 20 to 64 years old who had at least one ED visit for asthma from April 1, 2006 to March 31, 2008. Detailed information on ED management strategies was available on a subset of 37 sites whose staff attended pathway implementation workshops. MEASUREMENTS AND MAIN RESULTS: A total of 41,140 asthma visits to 167 EDs were analyzed. Most patients (64.8%) were triaged as high acuity and the majority (92.8%) were discharged. The return-visit rate was 2.8%. Female gender, younger age, higher acuity, leaving the ED before visit completion and prior admission or ED visit for asthma were associated with increased odds of a return visit. The only management strategy associated with reduced ED visits was access to 24-hour peak flow measurement. CONCLUSION: This study identified well-recognized patient- and hospital-level risk factors for return ED visits. Access to peak flow monitoring was the only protective management strategy found. As many ED asthma service and care gaps exist, province-wide implementation of a standardized care pathway may greatly impact ED management and improve patient outcomes including return ED visits.

Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness.

Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations. To evaluate the effects of PSH on Medicaid enrollees across New Jersey. Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement. A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014. PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC). Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.

Association of pharmacist counseling with adherence, 30-day readmission, and mortality: A systematic review and meta-analysis of randomized trials

Objective(s)To determine the association of pharmacist medication counseling with medication adherence, 30-day hospital readmission, and mortality. MethodsThe initial search identified 21,590 citations. After applying the inclusion and exclusion criteria, 62 randomized controlled trials (RCTs) (49 for the meta-analysis) were included in the final analysis. Data were pooled using a random-effects model. ResultsThe participants in most of the studies were older patients with chronic diseases who, therefore, were taking many drugs. The overall methodologic quality of evidence ranged from low to very low. Pharmacist medication counseling versus no such counseling was associated with a statistically significant 30% increase in relative risk (RR) for medication adherence, a 24% RR reduction in 30-day hospital readmission (number needed to treat = 4.2), and a 30% RR reduction in emergency department visits. RR reductions for primary care visits and mortality were not statistically significant. ConclusionThe evidence supports pharmacist medication counseling to increase medication adherence and to reduce 30-day hospital readmissions and emergency department visits. However, higher-quality RCT studies are needed to confirm or refute these findings.

Where Did All the Appendicitis Go? Impact of the COVID-19 Pandemic on Volume, Management, and Outcomes of Acute Appendicitis in a Nationwide, Multicenter Analysis.

The study objective was to evaluate effects of the COVID-19 pandemic on rates of emergency department (ED) acute appendicitis presentation, management strategies, and patient outcomes. Acute appendicitis is the most commonly performed emergency surgery in the United States and is unlikely to improve without medical or surgical intervention. Dramatic reductions in ED visits prompted concern that individuals with serious conditions, such as acute appendicitis, were deferring treatment for fear of contracting COVID-19. Patients from 146 hospitals with diagnosed appendicitis and arrival between March 2016 and May 2020 were selected. Electronic medical records data were retrospectively reviewed to retrieve patient data. Daily admissions were averaged from March 2016 through May 2019 and compared with March 2020. April-specific admissions were compared across the 5-year pre-COVID-19 period to April 2020 to identify differences in volume, demographics, disease severity, and outcomes. Appendicitis patient admissions in 2020 decreased throughout March into April, with April experiencing the fewest admissions. April 2020 experienced a substantial decrease in patients who presented with appendicitis, dropping 25.4%, from an average of 2030 patients (2016-2019) to 1516 in 2020. An even greater decrease of 33.8% was observed in pediatric patients (age <18). Overall, 77% of the 146 hospitals experienced a reduction in appendicitis admissions. There were no differences between years in percent of patients treated nonoperatively (P = 0.493) incidence of shock (P = 0.95), mortality (P = 0.24), or need for postoperative procedures (P = 0.81). Acute appendicitis presentations decreased significantly during the COVID-19 pandemic, while overall management and patient outcomes did not differ from previous years. Further research is needed focusing on putative explanations for decreased hospital presentations unrelated to COVID-19 infection and possible implications for surgical management of uncomplicated acute appendicitis.Keywords: acute appendicitis, COVID-19, decreasing volumes, multicenter study.

Institution-initiated Text Messaging and Telehealth Services Can Reduce Emergency Department Visits After Appendectomy.

Institution-initiated Text Messaging and Telehealth Services Can Reduce Emergency Department Visits After Appendectomy.

122 Regimented Phosphodiesterase Type 5 Inhibitor Use Reduces Emergency Department Visits for Recurrent Ischemic Priapism

Priapism is an erection disorder defined by an undesirable and often painful penile erection that persists in the absence of sexual desire or arousal. Recurrent ischemic priapism (RIP) manifests as multiple repetitive episodes over time and can have potentially irreversible pathologic consequences. The ideal strategy for managing RIP is preventative therapy. Current treatment options are often ineffective, have significant adverse effects, and have limited evidence. A recently recognized proposal has been the use of regimented phosphodiesterase type 5 inhibitor (regPDE5i) therapy intended to modulate the deranged regulatory mechanisms of penile erection in RIP. Previous reports on this strategy, mostly in small clinical trials and case series, have documented encouraging outcomes. However, its effectiveness as a treatment in use more extensively in real-world clinical practice remains to be shown.

Association of social risks with avoiding or delaying health care and with emergency department visits: evidence from 2017 Ohio Medicaid Assessment Survey.

The primary aim was to examine the association of social risks with avoiding/delaying health care after controlling for sociodemographic covariates, and the secondary aim was to examine the association of social risks with emergency department (ED) visits after controlling for avoiding/delaying health care and sociodemographic covariates. 2017 Ohio Medicaid Assessment Survey data were analyzed. Descriptive, bivariate analysis and multiple weighted logistic regressions were conducted. First, weighted logistic regression assessed the association of aggregated social risk (food insecurity, housing instability, financial strain) and health insurance type with avoiding/delaying health care after controlling for sociodemographic covariates. Next, weighted logistic regression assessed the association of social risks with ED visits after controlling for avoiding/delaying health care and sociodemographic covariates. Among 39,711 respondents, 21.7% reported avoiding/delaying health care and 27.2% reported having at least 1 ED visit in the past year. Individuals with higher vs lower aggregated social risk had higher odds of avoiding/delaying health care (odds ratio [OR], 1.30; 95% CI, 1.26-1.34) and were more likely to have any ED visits (OR, 1.10; 95% CI, 1.07-1.13). Uninsured individuals compared with those with private insurance were more likely to avoid/delay health care (OR, 1.98; 95% CI, 1.73-2.26) and have higher likelihood of any ED visits (OR, 1.23; 95% CI, 1.06-1.42). Finally, individuals who reported avoiding/delaying getting health care were more likely to have higher odds of any ED visits (OR, 1.33; 95% CI, 1.23-1.45). Social risks are important factors in patients' decisions to avoid/delay health care and are associated with increased odds of any ED visits. To reduce ED visits, policy-level efforts need to be made to address these social challenges.

Nurse Practitioner-Managed Clinic Reduces Emergency Department Visits for Parents of Children With Problematic Gastrostomy Tubes

Background Gastrostomy tube (G-tube) placement is commonly performed on pediatric patients but has high rates of emergency department (ED) utilization. We hypothesized that a nurse-practitioner-driven G-tube clinic would reduce ED visits and complications and improve provider and patient satisfaction. Methods After institutional review board approval, a retrospective chart review was conducted for all patients &lt; 18 years old undergoing G-tube placement between January 2014 and June 2018. Data collected included demographics, indication, and type of G-tube as well as ED visits, clinic visits, and outcomes up to 1-year postoperative. Surveys were distributed to providers and parents to assess attitudes toward the clinic. Results There was a decrease in the number of physician clinic visits, but there was no difference in overall 30- or 90-day ED visits after institution of the G-Tube Clinic. In the cohort of patients who had problematic G-tube-related problems, such as granulation, plugged tube, or tube dislodgement, creation of the G-Tube Clinic significantly reduced 30-day (0.37 vs. 0.07, p = .0008), 90-day (0.27 vs. 0.73, p = .0031), and 1-year (0.6 vs. 1.18, p = .014) ED visits. Surgeon and patient satisfaction were improved with clinic implementation. Conclusions Implementation of a nurse-practitioner-managed clinic resulted in reduction in 30-day, 90-day, and 1-year ED visits among patients with gastrostomy issues and is associated with high levels of patient and provider satisfaction.

Postoperative Telehealth Visits Reduce Emergency Department Visits and 30-Day Readmissions in Elective Thoracic Surgery Patients.

Preventing postoperative 30-day readmissions requires an investment in patient care. The use of postdischarge telehealth visits to prevent potential adverse events or hospital visits has been shown in previous studies. We aim to determine the impact of postoperative telehealth visits (PTV) on reducing emergency department visits (EDV) and readmissions within 30 days postdischarge (30DR). All elective thoracic surgery patients opted-in or opted-out of PTV. Postoperative telehealth visits assessed patients' overall health status and addressed patient concerns. Patients were also seen at their postoperative clinic follow-up. Emergency department visits and 30DR were recorded. Three hundred fourty-one patients were included-295 and 46 patients opted-in and opted-out of PTV. Opting-out of PTV, being discharged with chest tubes or drains, and the inability to perform activities of daily living at their postoperative follow-up were associated with increased EDV (OR = 8.7, 5.3, 6.3; p ≤ .05) and 30DR (OR = 5.1, 6.3, 7.1; p ≤ .05). Postoperative telehealth visits were able to reduce EDV and 30DR in our study, although further studies establishing the range of interventions that can be feasibly provided remotely should be performed to identify limitations of these PTV. Telehealth could be used postoperatively to reduce EDV and 30DR, improving quality and cost-effectiveness of healthcare delivery to patients.