Significant Increase In Utilization Research Articles

Enhanced Disease-Specific Survival Among Individuals With Malignant Adnexal Tumors of the Skin Treated With Mohs Surgery: A National Database Study.

Malignant adnexal tumors of the skin are a rare group of tumors that can be locally aggressive and require surgical excision with strict margin control to achieve clearance. Given the rarity of these tumors, there is a limited understanding within the medical community regarding optimal treatment approaches. To examine surgical management trends and outcomes for patients diagnosed with cutaneous adnexal tumors from 2000 to 2020. The Surveillance, Epidemiology, and End Results database was queried to identify biopsy-proven cases of cutaneous adnexal tumors between 2000 and 2020. Clinical and disease characteristics were examined, and disease-specific survivals were compared between surgical approaches using Kaplan-Meier curves and Cox proportional hazards models. Mohs surgery demonstrated a significant increase in utilization from 2000 to 2020 (+447.1%) and improvements in disease-specific survival (mean 231.7 months; p < .001) compared with no surgery; wide local excision exhibited no improved disease-specific survival (227.7 months; p = .070). Multivariable Cox regression further highlighted that only Mohs surgery exhibited a reduced disease-specific mortality risk compared with no surgery (adjusted HR 0.49; p = .011). Given the enhanced disease-specific survival coupled with tissue preservation strategies, Mohs surgery emerges as a promising surgical approach for the treatment of malignant adnexal tumors of the skin.

Utilization of Immediate Postpartum Contraception and Its Association with Interpregnancy Interval: 10-Year Experience at a Single Center.

Increasing availability of immediate postpartum long-acting reversible contraception (LARC) has added contraceptive alternatives to bilateral tubal ligation (BTL) in the immediate postpartum period. The resultant access to long-term contraception has provided patients with improved control over the timing of pregnancies. Our objective is to evaluate changes in the utilization of immediate postpartum contraceptive methods over a 10-year period and its association with interpregnancy interval (IPI). Retrospective cohort study of 36,445 patients delivered at a single academic hospital center from 2012 to 2020. Deliveries <23 weeks gestation and patients who underwent a cesarean hysterectomy or postpartum hysterectomy for obstetric indications were excluded. The primary outcome was the utilization of postpartum BTL, intrauterine devices, contraceptive implants, and Depo-Provera over the study time period. The secondary outcomes were IPI and interdelivery interval (IDI). Outcomes were compared using appropriate tests of trend. We adjusted for significant covariates as assessed in baseline characteristics. A total of 35,281 patients were included in our study. Groups were different in baseline characteristics including age, race/ethnicity, parity, BMI, insurance status, comorbidity risk, and attendance at postpartum exam. Over the study period, there was a significant difference in utilization of Depo-Provera, LARC, intrauterine device (IUD), and implant (p < 0.001). There was a significant increase in IPI (p < 0.001) and IDI (p < 0.001). We observed a significant increase in utilization of immediate postpartum LARC over the study period which corresponded to a significant increase in IPI and IDI. Our findings emphasize the importance of the availability of immediate postpartum contraception as well as its effectiveness in improving family planning options for reproductive-aged patients. We found significantly increased IPI and IDI associated with increased utilization of long-acting reversible contraceptives immediately postpartum. Our findings emphasize the importance of providers offering these options to patients as well as being comfortable initiating immediate postpartum contraception. · Immediate postpartum LARC access has increased over the past 10 years.. · Access to more methods of contraception allows patients more options for family planning.. · Increased utilization of LARC led to increased IPI and IDI..

Economic Evaluation of an Enhanced Post-Discharge Home-Based Care Program for Stroke Survivors

ObjectivesTo examine the cost-effectiveness of an enhanced postdischarge home-based care program for stroke survivors compared with usual care. MethodsThis was a trial-based economic evaluation study. One hundred and sixteen patients with ischemic stroke were recruited from neurology units in a Chinese hospital and randomized into intervention (n = 58) or usual care groups (n = 58). The intervention commenced with predischarge planning and transitioned to home follow-up postdischarge. Trained nurse case managers supported by an interdisciplinary team provided comprehensive assessment, individualized goal setting, and skill training to support home-based rehabilitation for intervention group participants. Standard care was provided to usual care group participants. Total cost and quality-adjusted life-years gained at 3-month (T1), 6-month (T2), and 12-month (T3) follow-ups were calculated. The incremental cost-effectiveness ratios between the groups were obtained. ResultsThe intervention group showed a significant increase in utility compared with the usual care group at T1 (P = .003), T2 (P = .007), and T3 (P < .001). The average total QALY gain from baseline for the intervention group was higher than for the usual care group at all time points. The likelihood of being cost-effective ranged from 61.9% to 67.2% from the provider perspective, and from 59.7% to 66.8% from the societal perspective. ConclusionsThe results showed that the intervention program was cost-effective with significantly higher quality-adjusted life-years for stroke survivors when compared with usual care. It provides economic evidence to support the development of home-based stroke rehabilitation program, especially in the low- and middle-income countries.

Patterns of Outpatient IVIG Use before and during the COVID Pandemic in Patients with Multiple Myeloma

Background: Infections in patients with multiple myeloma are a frequent cause of morbidity and mortality. Intravenous immunoglobulin (IVIG) replacement is a preventative strategy for infection risk reduction. The NCCN guidelines recommend IVIG therapy should be considered in the setting of recurrent serious infection and/or hypogammaglobinemia. The IMWG suggests a targeted use, limiting replacement to patients with IgG concentrations less than 400mg/dl and who have serious recurrent encapsulated bacterial infections. In this study, we sought to describe patterns of IVIG use prior to and during the COVID-19 epidemic. Methods: In this cross-section study, we sought to describe real-world patterns of outpatient IVIG use before and during the COVID-19 pandemic using the IBM MarketScan Commercial Claims and Encounters (CCAE) and Medicare Supplemental and Coordination of Benefits (COB, a.k.a. MDCR) databases. MarketScan is an administrative database of diagnostic and treatment data for more than 30 million commercially insured individuals in the United States. Patients included in this study had private insurance or were enrolled in a Medicare advantage plan. IVIG administration data was grouped by patient age, sex, geographic region, and metropolitan area defined by the Census Metropolitan Statistical Area,. Pre-pandemic time period is defined as the time prior to March 2020. Results: Our study showed changes in patterns of IVIG use with respect to patient age, sex, geographic region, and location of care delivery. A total of 12,893 patients were identified with multiple myeloma during this study period. Patients greater than age 65 made up 31.3% of the cohort. Location of IVIG administration was outpatient hospital (32.6%), Office (40.2%), Patient home (14.9%) and other (0.9%). Pre-pandemic IVIG usage rate in this cohort was 3.37 IVIG administrations per 100 patients studied compared to post-pandemic usage rate increased to 3.6 per 100 patients (p=0.038). A significant increase in utilization is noted by age with usage rate in patients over age 65 increasing from 1.96 to 2.54 (p&amp;lt;0.001). Prior to the pandemic, usage rate for males was 2.2 and increased to 2.51 after the pandemic (p&amp;lt;0.001). For females, usage rate also increased from 2.42 to 2.58 (p=0.07). Changes in utilization also occurred regionally with increased use in the Northeast and West. Usage rates in the Northeast prior to the pandemic were 2.37 compared to 3.28 IVIG administration (p&amp;lt;0.001). Similarly, pre-pandemic utilization rates in the West were 2.55 and increased to 3.21 (p&amp;lt;0.001). Usage rates were stable in the North Central region, only increasing from 2.09 to 2.15 (p=0.54). Interestingly, usage rates decreased slightly in the Southern region from 2.32 to 2.24 post pandemic (p=0.38). Metropolitan service areas saw a slight increase in utilization from 2.41 to 2.56 (p=0.06). However, non-metropolitan service areas had an increase from 2.1 to 2.56 (p&amp;lt;0.001). Conclusions: This study describes the variation in outpatient IVIG use by age, geographic region, sex and location of treatment before and during the COVID-19 pandemic. During the COVID-19 pandemic, there was significant uncertainty regarding optimal infection risk mitigation strategies for patients with multiple myeloma. In this real-world review of clinical practice patterns, variations in outpatient use of IVIG can be seen to vary most based on geographic region and patient age. Statistically significant increases are also seen in males and in non-metropolitan areas. Patients in regions impacted earliest and hardest by increase in COVID-19 infections saw the greatest increase in the use of IVIG while other regions saw stable or decreased utilization. Additionally, patients over age 65, who were at greatest risk for negative outcomes of COVID-19 infections saw the greatest increase in utilization compared to pre-pandemic rates. In the post pandemic time period, patients over age 65 continued to have statistically significant increased rates of utilization while patients less than age 65 also increased rates of utilization that was not statistically significantly increased. This study is limited by lack of clinical information including COVID 19 infection status and concomitant myeloma therapy. The variation in utilization of IVIG illustrates the need for prospective studies to guide its use.

Utilization of access to colorectal cancer screening modalities in low-income populations after medicaid expansion.

Colorectal cancer (CRC) remains a relevant public health problem. Current research suggests that racial, economic and geographic disparities impact access. Despite the expansion of Medicaid eligibility as a key component of the Affordable Care Act (ACA), there is a dearth of information on the utilization of newly gained access to CRC screening by low-income individuals. This study investigates the impact of the ACA's Medicaid expansion on utilization of the various CRC screening modalities by low-income participants. Our working hypothesis is that Medicaid expansion will increase access and utilization of CRC screening by low-income participants. To investigate the impact of the Affordable Care Act and in particular the effect of Medicaid expansion on access and utilization of CRC screening modalities by Medicaid state expansion status across the United States. This was a quasi-experimental study design using data from the Behavioral Risk Factor Surveillance System, a large health system survey for participants across the United States and with over 2.8 million responses. The period of the study was from 2011 to 2016 which was dichotomized as pre-ACA Medicaid expansion (2011-2013) and post-ACA Medicaid expansion (2014-2016). The change in utilization of access to CRC screening strategies between the expansion periods were analyzed as the dependent variables. Secondary analyses included stratification of the access by ethnicity/race, income, and education status. A greater increase in utilization of access to CRC screening was observed in Medicaid expansion states than in non-expansion states [+2.9%; 95% confidence interval (95%CI): 2.12, 3.69]. Low-income participants showed a +4.02% (95%CI: 2.96, 5.07) change between the expansion periods compared with higher income groups +3.19% (1.70, 4.67). Non-Hispanic Whites and Hispanics [+3.01% (95%CI: 2.16, 3.85) vs +5.51% (95%CI: 2.81, 8.20)] showed a statistically significant increase in utilization of access but not in Non-Hispanic Blacks, or Multiracial. There was an increase in utilization across all educational levels. This was significant among those who reported having a high school graduate degree or more +4.26 % (95%CI: 3.16, 5.35) compared to some high school or less +1.59% (95%CI: -1.37, 4.55). Medicaid expansion under the Affordable Care Act led to an overall increase in self-reported use of CRC screening tests by adults aged 50-64 years in the United States. This finding was consistent across all low-income populations, but not all races or levels of education.

Association Between California’s State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery

Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies. To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents. Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019. California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013. Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure. A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001). Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.

Promoting Access to Innovative Anticancer Medicines: A Review of Drug Price and National Reimbursement Negotiation in China.

Providing universal access to high-cost medications like anticancer drugs is not an easy feat. Although basic medical insurance has covered over 95% of China's population since 2012, reimbursement for high-priced medicines is limited. In 2015, the Chinese government proposed establishing an open and transparent price negotiation mechanism for some patented and expensive drugs, where oncology was among the prioritized areas. In 2016, three drugs (gefitinib, icotinib, and tenofovir disoprox) underwent negotiation with the government, eventually reducing their prices by over 50% so that they could be prioritized during reimbursement processes. Focusing on anticancer medicines, this study comprehensively summarizes the progress in drug price and national reimbursement negotiation in China. Furthermore, we investigated the changes and development regarding negotiated anticancer medicines from quantity negotiated, classification, indication coverage, utilization, and procurement spending. Our findings could provide a reference for follow-up negotiations and reimbursement policies for high-value anticancer medications in other countries. From 2016 to 2021, 82 anticancer medicines were newly incorporated into the national reimbursement drug list (NRDL) via 6 rounds of negotiation. The majority of these were innovative pharmaceutics (ie, protein kinase inhibitors (28) and monoclonal antibodies (13)). Drug pricing and national reimbursement negotiation led to a marked decrease in prices and a sharp increase in the utilization of negotiated anticancer medicines. Following negotiations, the defined daily doses (DDDs) of innovative anticancer medicines experienced remarkable growth. Their proportion in total anticancer drugs DDDs also increased from 3.4% in 2014 to 20.9% in 2019. However, although drug prices decreased substantially after the negotiations, insurance spending still showed an upward trend owing to the significant increase in utilization. This calls for the government to carefully monitor the rational use of these expensive medicines and explore innovative payment models.

The Dallas Donation after Circulatory Death Transplantation Summit: expanding donation after circulatory death procedures through process improvement, broader utilization, and innovation.

Despite a significant increase in utilization over the past decade, the number of donation after circulatory death (DCD) organs that are procured and transplanted in the United States (US) remains well below its potential. There is still room for expansion, as utilizing DCD organs to the fullest extent is currently the most viable solution to the persistent mismatch between supply and demand in transplantation. We convened a multidisciplinary transplantation summit to examine various aspects of DCD, with faculty members from around the world with clinical and academic interest in DCD donation and transplantation, including abdominal and cardiothoracic surgeons, organ procurement organization directors, hepatologists, and gastroenterologists. The conference focused on identifying barriers to DCD organ utilization and strategies to overcome these barriers. We divide the barriers to DCD utilization into three mains categories: (I) policy and process variation; (II) logistical and transportation challenges; and (III) higher risk perceptions related to DCD outcomes. For each barrier, we proposed a variety of solutions, providing an overview of the status of DCD donation in the US and suggestions on how to increase the use of DCD. There is a specific focus on ex situ machine perfusion, normothermic regional perfusion, and other opportunities to expand DCD utilization without negatively impacting recipient outcomes.

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.

Nitrate Contamination in Gurugram District, Haryana

Groundwater has witnessed a significant increase in utilisation in recent decades due to its widespreadavailability and typically acceptable quality. Contamination of groundwater with nitrates and the associatedhealth hazards is one of the most prevalent challenges affecting groundwater quality around the world.Nitrate (NO3–) is a particularly important groundwater pollutant because of its widespread presence inaquifers and its health and environmental consequences. Nitrate is present in nature as a by-product ofagricultural and animal manure, as well as in anthropogenic waste. The purpose of this study was todetermine the nitrate content in groundwater in various villages in Gurugram, Sohna, Farukh Nagar, andPataudi block of Gurugram district, Haryana, where groundwater is the primary source of drinking water.Samples of groundwater from 156 wells were collected and analyzed the nitrate concentration. The minimumnitrate concentration of 1.23 mg/l as NO3 was observed in Sherpur village of Pataudi Block of GurugramDistrict. The maximum concentration (102 mg/l as NO3) was measured for Kankrola of Gurugram block ofGurugram district. Seventy eight percent of the samples had values under 45 mg/l, 22.43 % had valuesbetween 0-10 mg/l, 26.92% had values between 11-20 mg/l, 15.38 % had values between 21-30 mg/l, 11.53% had values between 31-40 mg/l and 22 % had values beyond 45 mg/l. All of the Sohna block samplesmeet the BIS 10500:2012 permissible limit. Data reveals that 34 villages exceeded out of 156 villages havingthe nitrate concentration (45 mg/l) above the limit.

Palliative care of COVID-19 patients with do-not-resuscitate status in underrepresented minorities.

The impact of the COVID-19 pandemic on palliative care intervention (PCIs) in patients with do-not-resuscitate (DNR) status remains uncertain. Case-control study of patients with DNR order with RT-PCR confirmed SARS-COV2 infection (cases), and those with DNR order but without SARS-COV2 infection (controls). The primary outcome measures included timing and delivery of PCIs, and secondary measures included pre-admission characteristics and in-hospital death. The ethnicity distribution was comparable between 69 cases and 138 controls, including Black/African Americans (61% vs. 44%), Latino/Hispanics (16% vs. 26%) and White (9% vs. 20%) (trend-p=.54). Cases were employed more (17% vs. 6%, adjusted-p=.012), less frail (fit 47% vs. 21%; mildly frail 22% vs. 36%; frail 31% vs. 43%, trend-p=.018) and had fewer comorbidities than controls. Cases had higher chances of intensive care unit admission (HR 1.76 [95% CI: 1.03-3.02]) and intubation (53% vs. 30%, p=.002), lower chances to be seen by palliative care team (HR .46 [.30-.70]) and a longer time to palliative care visit than controls (β per ln-day .67 [.00-1.34]). In the setting of no-visiting hospitals policy, we did not find significant increase in utilisation of video conferencing (22% vs. 13%) and religious services (12% vs. 12%) both in case and in controls. Do-not-resuscitate patients with COVID-19 had better general health and higher employment status than 'typical' DNR patients, but lower chances to be seen by the palliative care team. This study raises a question of the applicability of the current palliative care model in addressing the needs of DNR patients with COVID-19 during the pandemic.

247.3: Utility of Liver Biopsy in Liver Transplantation: Implications for Changes in Liver Allocation

Introduction: Histological evaluation of a potential donor liver can provide useful information prior to liver transplantation (LT) and potentially reduce discard rates. However, the use of a liver biopsy (LB) is not standardized across Organ Procurement Organizations. On February 4, 2020, the LT allocation policy in the United States changed, likely shifting institutional and regional behavior changes for the acceptance of donated organs. We sought to review LB utilization patterns before and after the institution of the acuity circle allocation system (ACAS) and determine if LB rates were associated with allograft discard rates, patient and graft survival. Methods: Data from the Scientific Registry of Transplant Recipients (SRTR) were analyzed on the utilization of LB before and after the implementation of ACAS. Era 1 was defined as January 1, 2018 to February 3, 2020; Era 2 was defined as February 4, 2020 to June 1, 2021. Statistical comparisons between eras were performed. Univariable and multivariable models were constructed to determine donor characteristics that were correlated with obtaining a LB during the eras. Kaplan-Meier survival analysis was performed to determine the impact of LB on patient and graft survival. Results: We analyzed 29,905 liver transplants performed from January 1, 2018 to June 1, 2021; 17,949 (60%) were performed in Era 1 and 11,956 (40%) were performed in Era 2. During the study time period, there were 11,043 LB performed; 6,488 (58.8%) in Era 1 and 4,555 (41.2%) in Era 2 (p<0.001). Era 1 demonstrated a LB rate of 36.1% while Era 2 demonstrated a LB rate of 38.1% (p<0.001). Donor characteristics associated with obtaining a LB were BMI, race, age, history of DM, and era. The discard rate between Era 1 (15.8%) and Era 2 (15.0%) did not differ (p=0.097). The 1- and 3-year patient survival for LT recipients was 93.3% and 83.5%, resp., and graft survival during Era 1 was 96.7% and 94.4%, respectively. The 1-year patient survival for LT recipients during Era 2 was 89.9% and graft survival was 96.1%. Conclusion: The institution of the ACAS led to differing acceptance practices around liver transplantation. In the time period after institution of the model, there was a statistically significant increase in utilization of LB, likely due to wider catchment areas for potential recipients. ACAS seemed to have no effect on the rates of allograft discard rates, patient, or graft survival.

Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics. The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant. We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7days in 2007 to 6days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014. Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

Automated vetting of radiology referrals: exploring natural language processing and traditional machine learning approaches

BackgroundWith a significant increase in utilisation of computed tomography (CT), inappropriate imaging is a significant concern. Manual justification audits of radiology referrals are time-consuming and require financial resources. We aimed to retrospectively audit justification of brain CT referrals by applying natural language processing and traditional machine learning (ML) techniques to predict their justification based on the audit outcomes.MethodsTwo human experts retrospectively analysed justification of 375 adult brain CT referrals performed in a tertiary referral hospital during the 2019 calendar year, using a cloud-based platform for structured referring. Cohen’s kappa was computed to measure inter-rater reliability. Referrals were represented as bag-of-words (BOW) and term frequency-inverse document frequency models. Text preprocessing techniques, including custom stop words (CSW) and spell correction (SC), were applied to the referral text. Logistic regression, random forest, and support vector machines (SVM) were used to predict the justification of referrals. A test set (300/75) was used to compute weighted accuracy, sensitivity, specificity, and the area under the curve (AUC).ResultsIn total, 253 (67.5%) examinations were deemed justified, 75 (20.0%) as unjustified, and 47 (12.5%) as maybe justified. The agreement between the annotators was strong (κ = 0.835). The BOW + CSW + SC + SVM outperformed other binary models with a weighted accuracy of 92%, a sensitivity of 91%, a specificity of 93%, and an AUC of 0.948.ConclusionsTraditional ML models can accurately predict justification of unstructured brain CT referrals. This offers potential for automated justification analysis of CT referrals in clinical departments.

Employer-based insurance coverage increases utilization of planned oocyte cryopreservation.

To determine the utilization of planned oocyte cryopreservation (OC) in the year immediately prior to, and the year of, insurance coverage commencement for employees at our institution. Patient demographics and cycle outcomes were retrospectively compared between the first OC cycles occurring in 2017 vs. 2018 according to insurance coverage and type, age, and the number of oocytes retrieved and cryopreserved. Continuous demographic variables including age, BMI, day 3 FSH and E2, AMH, gravidity, and parity were compared using student T-tests. Cycle outcomes, including the number of oocytes retrieved and cryopreserved were compared using linear regression models, adjusting for potential confounders including age, BMI, and ovarian reserve parameters. Between January 2017 and December 2018, 123 patients underwent planned OC at our institution. Patient age ranged from 23 to 44years and did not significantly differ from 2017 to 2018 (mean 34.9 vs. 35.2). There was a 12% increase in planned OC utilization from 2017 (N = 58) to 2018 (N = 65). Significantly, more patients had any insurance coverage in 2018 vs. 2017 (71.9% vs. 40.4%, p = 0.001), a 78% increase. From 2017 to 2018, the number of patients with hospital-based insurance coverage undergoing planned OC increased by a factor of 8 (5 to 41.5%, p < 0.001), while the number of self-pay patients significantly decreased (p = 0.001). No differences were found regarding cycle outcomes. A greater proportion of women at our institution had insurance coverage for planned OC in 2018 vs. 2017. Employer-based insurance coverage for planned OC was associated with a significant increase in utilization by hospital employees.

Physiological Changes in Response to Skeletal Muscle Specific High Expression of mu‐Crystallin Following High and Low‐Fat Diets

Approximately 20 percent of the population expresses high levels of the thyroid hormone binding protein mu‐crystallin in skeletal muscle while the rest of the population expresses little to no mu‐crystallin. Since the thyroid hormones, T3 and T4, are potent regulators of metabolism and thermogenic regulation, our studies focus on the consequences of skeletal‐specific high expression (SM‐HE) of mu‐crystallin. We hypothesize that SM‐HE of mu‐crystallin influences cellular and metabolic changes in a diet‐ and sex‐ specific manner by influencing changes in gene expression.To evaluate this, we generated transgenic mice (Crym‐tg) that over‐express mu‐crystallin in skeletal muscle, equivalent to human high expressors, which resulted in high levels of accumulation of T3 in muscle tissue. Respiratory exchange ratio (RER) in these mice indicated a small but significant increase in utilization of fat as an energy source.In high‐ and low‐fat diet studies, we found differences between Crym‐tg and controls as well as sex specific differences. Following a 16‐week exposure, Crym‐tg males on high‐fat diet and Crym‐tg females on low‐fat diet weighed more than controls whereas Crym‐tg males on low‐fat diet and Crym‐tg females on high‐fat diet weighed less than controls. These differences were consistent with the results of glucose tolerance tests, in which only the Crym‐tg mice that weighed more than controls showed a significant increase in sensitivity to glucose. We are currently evaluating these results to understand their basis in transcriptomic and proteomic data, which have already revealed increased expression of genes involved in fatty acid oxidation and decreased expression of genes involved in glycolytic metabolism (Kinney et al. (2021) Curr Res Physiol. 4:47‐59.) as well as some members of the insulin signaling pathway.

MP23-06 NEOADJUVANT CHEMOTHERAPY BEFORE RADICAL CYSTECTOMY FOR MUSCLE-INVASIVE BLADDER CANCER: PATIENT, PROVIDER, AND CLINICAL ETIOLOGIES FOR LACK OF UTILIZATION

You have accessJournal of UrologyCME1 May 2022MP23-06 NEOADJUVANT CHEMOTHERAPY BEFORE RADICAL CYSTECTOMY FOR MUSCLE-INVASIVE BLADDER CANCER: PATIENT, PROVIDER, AND CLINICAL ETIOLOGIES FOR LACK OF UTILIZATION Hiten D. Patel, Ushasi Naha, Victor S. Chen, Caitlyn Ko, Rachel Yang, Aleksander Druck, Goran Rac, and Marcus L. Quek Hiten D. PatelHiten D. Patel More articles by this author , Ushasi NahaUshasi Naha More articles by this author , Victor S. ChenVictor S. Chen More articles by this author , Caitlyn KoCaitlyn Ko More articles by this author , Rachel YangRachel Yang More articles by this author , Aleksander DruckAleksander Druck More articles by this author , Goran RacGoran Rac More articles by this author , and Marcus L. QuekMarcus L. Quek More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002562.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Neoadjuvant chemotherapy (NAC) represents a standard of care prior to radical cystectomy for muscle-invasive bladder cancer (MIBC; ≥cT2). While NAC utilization has increased over time in the United States, many patients may not receive NAC due to reasons that are difficult to identify in administrative or registry data. We aimed to assess utilization of NAC and etiologies for lack of NAC receipt among consecutive patients at a single institution. METHODS: Patients diagnosed with bladder cancer and undergoing radical cystectomy at Loyola University Medical Center (2005-2021) were included. Clinical variables included age, sex, race, comorbidities, prior intravesical therapy, hydronephrosis, histology, clinical stage, and surgical approach. Patients were categorized by stage and receipt of NAC. Early and recent time periods were evaluated among all ≥cT2 patients and after exclusion of non-candidates. Reasons for no NAC were categorized. Overall survival (OS) was evaluated with Kaplan-Meier curves and multivariable Cox proportional hazards regression models. RESULTS: Of 589 evaluable patients, 380 (64.5%) had ≥cT2 disease and 209 (35.5%) <cT2. Among ≥cT2 patients, a total of 155 (40.8%) received NAC with significant increase in utilization from the early to recent time periods (22.8% to 67.8%, p <0.001). Utilization of NAC was similar for open and robotic approach (p=0.15). Among 225 patients not receiving NAC, reasons included renal dysfunction (28.0%), patient symptoms (9.3%), concern for disease progression (8.4%), salvage setting (3.1%), patient preference/refusal (24.4%), and provider recommendation (26.7%). Provider recommendation was related to comorbidities (18/60 (30.0%); e.g. prior chemotherapy, hearing loss, non-renal comorbidity), histology (20/60 (33.3%); e.g. squamous or adenocarcinoma histology), or not mentioned (22/60 (36.7%)). After excluding non-candidates for NAC, increase in utilization from the early to recent time periods was 34.2% to 85.8% (p <0.001). Patient preference/refusal decreased from 29.0% to 8.2% in the early to recent time periods (p <0.001). NAC was associated with improved OS (HR 0.54, p=0.003). Patients with reasons to forgo NAC had worse OS including due to renal dysfunction (HR 1.98, p=0.007), symptoms (HR 2.27, p=0.03), or provider recommendation (HR 2.35, p=0.002). CONCLUSIONS: NAC utilization increased over time with change in estimates before and after exclusion of non-candidates. Renal dysfunction, patient preference, and provider recommendation based on histologic or clinical concerns were primary etiologies for lack of NAC prior to radical cystectomy for muscle-invasive bladder cancer. Fewer patients refused NAC in recent years leading to a potential ceiling for NAC utilization. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e383 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hiten D. Patel More articles by this author Ushasi Naha More articles by this author Victor S. Chen More articles by this author Caitlyn Ko More articles by this author Rachel Yang More articles by this author Aleksander Druck More articles by this author Goran Rac More articles by this author Marcus L. Quek More articles by this author Expand All Advertisement PDF downloadLoading ...

Abstract TP130: Racial Differences In Palliative Care Utilization And Impact On Inpatient Mortality Length Stay And Costs Among Patients With Intracerebral Hemorrhage

Background and Purpose: Palliative is increasingly used in critically ill patients which has lead to shorter length of stays, higher inpatient mortality and lower utilization of aggressive treatment. We performed analysis to evaluate trends in utilization of palliative care among patients with subarachnoid hemorrhage and its effect on in-hospital outcomes over a 10-year period. Methods: We obtained data for patients admitted to hospitals in the United States from 2009 to 2018 with a primary diagnosis of intracerebral hemorrhage (ICH) using a large national database. We determined the overall and among different races, rate of utilization of palliative care in patients with ICH and associated in-hospital outcomes consisting of mean hospital charges, mean length of stay and in-hospital mortality. Results: Out of 711787 patients admitted with primary diagnosis of ICH, palliative care was used in 105354 (14.8%). There was a 2.5-fold increase in utilization of PC (8.9% in 2009 vs 22.9% in 2018; p&lt;0.001). Similarly, there were 2.4, 2.6, 3.7 and 2.4-folds increase in utilization of PC among different races: whites, blacks, hispanics and others respectively, p&lt;0.001. Overall rates of PC utilization among different races: whites, blacks, hispanics and others were: 17.4%, 9.8%, 10.1% and 12.2%, p&lt;0.001 respectively. The length of hospitalization remained significantly lower (4.8±7.8 versus 7.7±10.8, p&lt;0.001) in patients undergoing PC compared with those who did not. The cost of hospitalization remained significantly lower ($54736 ± 94502 versus $ 79426 ± 124617, p&lt;0.001) in patients undergoing PC compared with those who did not. Patients with PC utilization had significantly higher (64.9% versus 13.7%, p&lt;0.001) in-hospital mortality compared ones with out. Conclusions: Between 2009 and 2018, there has been a significant increase in utilization of PC among patients with ICH along with shorter length of stay and lower hospital charges. ICH patients with PC had significantly higher in-hospital mortality.

Abstract TP112: Racial Differences In Palliative Care Utilization And Impact On Inpatient Mortality Length Stay And Costs Among Patients With Ischemic Stroke

Background and Purpose: Palliative is increasingly used in critically ill patients which has lead to shorter length of stays, higher inpatient mortality and lower utilization of aggressive treatment. We performed analysis to evaluate trends in utilization of palliative care among patients with Ischemic Stroke and its effect on in-hospital outcomes over a 10-year period. Methods: We obtained data for patients admitted to hospitals in the United States from 2009 to 2018 with a primary diagnosis of Ischemic stroke (IS) using a large national database. We determined the overall and among different races, rate of utilization of palliative care in patients with IS and associated in-hospital outcomes consisting of mean hospital charges, mean length of stay and in-hospital mortality. Results: Out of 5525248 patients admitted with primary diagnosis of IS, palliative care was used in 150301 (2.72%). There was a 1.05-fold utilization of PC (1.69% in 2009 vs 1.78% in 2018; p&lt;0.001) from 2009 till 2018. Similarly, there were 1.003, 1.4, 1.04 and 1.05-folds increase in utilization of PC among different races: whites, blacks, hispanics and others respectively, p&lt;0.001. Overall rates of PC utilization among different races: whites, blacks, hispanics and others were: 3.0%, 1.6%, 2.03% and 2.69%, p&lt;0.001 respectively. The length of hospitalization remained significantly higher (6.0±7.4 versus 3.8±5.2, p&lt;0.001) in patients undergoing PC compared those who did not. The cost of hospitalization remained significantly higher ($55068 ± 84630 versus $ 40148 ± 53479, p&lt;0.001) in patients undergoing PC compared with those who did not. Patients with PC utilization had significantly higher (42.9% versus 1.56%, p&lt;0.001) in-hospital mortality compared ones with out. Conclusions: Between 2009 and 2018, there has been a significant increase in utilization of PC among patients with IS along with longer length of stay and higher hospital charges. Patients with PC had significantly in-hospital morality. The findings in this IS population are paradoxical to what has been seen in other critical illnesses which may be related to differences in natural history.

Abstract TMP7: Racial Differences In Palliative Care Utilization And Impact On Inpatient Mortality Length Stay And Costs Among Patients With Subarachnoid Hemorrhage

Background and Purpose: Palliative is increasingly used in critically ill patients which has lead to shorter length of stays, higher inpatient mortality and lower utilization of aggressive treatment. We performed analysis to evaluate trends in utilization of palliative care among patients with subarachnoid hemorrhage and its effect on in-hospital outcomes over a 10-year period. Methods: We obtained data for patients admitted to hospitals in the United States from 2009 to 2018 with a primary diagnosis of subarachnoid hemorrhage (SAH) using a large national database. We determined the overall and sub racial rate of utilization of palliative care in patients with SAH and associated in-hospital outcomes consisting of mean hospital charges, mean length of stay and in-hospital mortality. Results: Out of 199928 patients admitted with primary diagnosis of SAH, palliative care was used in 20490 (10.2%). There was a 2.2-fold increase in utilization of PC (6.5%% in 2009 vs 14.4% in 2018; p&lt;0.001). Similarly, there were 1.7, 2.9, 3.2- and 4.6-folds increase in utilization of PC among different races: whites, blacks, hispanics and others respectively, p&lt;0.001. Overall rates of PC utilization among among different races: whites, blacks, hispanics and others were: 11.8%, 6.9%, 7.5% and 10.0%, p&lt;0.001 respectively. The length of hospitalization remained significantly lower in patients undergoing PC compared with those who did not. (6.5±9.9 versus 11.6±12.6, p&lt;0.001). The cost of hospitalization remained significantly lower in patients undergoing PC compared with those who did not. ($120526 ± 193412 versus $ 185116 ± 219434, p&lt;0.001). Patients with PC utilization had significantly higher (72.7% versus 13.6%, p&lt;0.001) in-hospital mortality compared ones with out. Conclusions: Between 2009 and 2018, there has been a significant increase in utilization of PC among patients with SAH along with shorter length of stay and lower hospital charges. SAH patients with PC had significantly higher in-hospital mortality.