Subsequent Inpatient Admission Research Articles

Hospital admissions among patients with Comorbid Substance Use disorders: a secondary analysis of predictors from the NavSTAR Trial

BackgroundIndividuals with substance use disorders (SUDs) frequently use acute hospital services. The Navigation Services to Avoid Rehospitalization (NavSTAR) trial found that a patient navigation intervention for hospitalized patients with comorbid SUDs reduced subsequent inpatient admissions compared to treatment-as-usual (TAU).MethodsThis secondary analysis extends previous findings from the NavSTAR trial by examining whether selected patient characteristics independently predicted hospital service utilization and moderated the effect of the NavSTAR intervention. Participants were 400 medical/surgical hospital patients with comorbid SUDs. We analyzed 30- and 90-day inpatient readmissions (one or more readmissions) and cumulative incidence of inpatient admissions through 12 months using multivariable logistic and negative binomial regression, respectively.ResultsConsistent with primary findings and controlling for patient factors, NavSTAR participants were less likely than TAU participants to be readmitted within 30 (P = 0.001) and 90 (P = 0.03) days and had fewer total readmissions over 12 months (P = 0.008). Hospitalization in the previous year (P < 0.001) was associated with cumulative readmissions over 12 months, whereas Medicaid insurance (P = 0.03) and index diagnoses of infection (P = 0.001) and injuries, poisonings, or procedural complications (P = 0.004) were associated with fewer readmissions. None of the selected covariates moderated the effect of the NavSTAR intervention.ConclusionsPrevious findings showed that patient navigation could reduce repeat hospital admissions among patients with comorbid SUDs. Several patient factors were independently associated with readmission. Future research should investigate risk factors for hospital readmission among patients with comorbid SUDs to optimize interventions.Trial RegistrationNIH ClinicalTrials.gov NCT02599818, Registered November 9, 2015 https://classic.clinicaltrials.gov/ct2/show/NCT02599818.

P1030 Inflammatory Bowel Disease helpline contact trends in a real-world Australasian cohort: Crohn’s Colitis Cure (CCC) data insight’s program

Abstract Background For optimal outcomes, Inflammatory Bowel Disease (IBD) necessitates lifelong engagement in care. Specialized-IBD-nurse-led helplines improve access to care and reduce associated costs1,2. Despite this evidence, IBD nurses and helplines receive variable funding and little is known about their use across care sites. We therefore analysed IBD-helpline usage in a large, multi-site real-world Australasian cohort. Methods Crohn’s Colitis Care (CCCare), is a cloud-based IBD-specific electronic medical record used in Australia and New Zealand. It includes a "Helpline" tab to support helpline encounter documentation during the point of contact. All entered data feed into an associated, de-identified clinical quality registry (CQR). Helpline-associated data fields, including contact reason and type, were extracted from CCCare’s CQR in November 2023. Data from 6 large adult care sites across Australia and New Zealand were analysed. Results In 2022, a total of 6,717 helpline encounters were documented. There was a roughly equal split in contact type; phone accounting for 50.9% (n=3,416) and email for 49.1% (n=3301). The most common reasons for contact were related to medications (n=2,577; 38.4%), investigations (n=1,719; 25.6%) and clinical (n=1,060; 15.8%). More encounters were seen in 2023 (to date of data extract), with 7,540 helpline entries to date (Figure 1). In 2023, the most common form of patient contact was email (70.3%), with phone contact accounting for only (29.8%). The most common reasons for contact were again related to medications (n=2,577; 31.1%), investigations (n=1,162; 22.0%) and clinical (n=1,439; 19.1%). In both years, helpline activity was lowest in January and February, perhaps corresponding to the Holiday season (southern hemisphere summer). Conclusion A number of helpline entries were recorded across these 2 years, with activity lowest each summer. The data show a shift in the predominant mode of contact from phone to email in 2023, reflecting evolving communication preferences and making scheduling of helpline support easier. 1 - Nicolaides S, Vasudevan A, Van Langenberg D. Inflammatory Bowel Disease Helpline Reduces Subsequent Inpatient Admission Rates. J Crohns Colitis. 2020 Feb 10;14(2):281. doi: 10.1093/ecco-jcc/jjz141. PMID: 31374121. 2 - Karimi N, Sechi AJ, Harb M, Sawyer E, Williams AJ, Ng W, Connor SJ. The effect of a nurse-led advice line and virtual clinic on inflammatory bowel disease service delivery: an Australian study. Eur J Gastroenterol Hepatol. 2021 Dec 1;33(1S Suppl 1):e771-e776. doi: 10.1097/MEG.0000000000002249. PMID: 34402467.

The consequence of the closure of primary care dental services on secondary care during the COVID-19 pandemic – A national outlook

BackgroundAfter the global pandemic of COVID-19 in March 2020, restrictions were implemented on all aspects of routine dental-care with a primary focus to urgent care only. AimTo investigate the impact on secondary care medical facilities and Emergency Department (ED) admissions for the management of severe dental infections as a result of restricted access to routine primary dental-care during the period of COVID-19 restrictions. DesignNational level Hospital Episode Statistics was used to describe the number of inpatient admissions for the drainage of a dental abscess and the attendance for dental related to ED. Data was stratified across ethnicity, sex and deprivation. ResultsThere was a decrease in admission to secondary care for dental infection and total admissions during the initial period of national lockdown due to COVID-19. Incidence of dental abscess drainage equalled 4.51 per100,000 person years from 2018 to 2021. There was a 209 % increase in admissions in patients with greatest deprivation. This was much more exaggerated compared to that of non-dental comparison conditions and total inpatient admissions. Using subsequent inpatient admission as a marker of severity, 4.2 % dentally related ED attendance required onward admission. ConclusionA large proportion of ED attendances with dental related conditions did not require inpatient admission, therefore a large proportion of ED attendances could be managed more appropriately in specific dental services. Dental infections requiring surgical admission disproportionality affects the most deprived communities of the population which is much more exaggerated compared to peri-anal and total inpatient admissions. This highlights the inequalities and links with deprivation that exist in oral and dental health in England, which is much greater than that of general health if total admissions are used as maker for this. This research highlights the need to improve access to primary dental-care services.

Medical advice lines offering on-demand access to providers reduced emergency department visits.

Instant access to clinicians through virtual care is designed to allow patients to receive care they need while avoiding high-cost visits in acute-care settings. This study investigates the effect of offering patients the option to instantly connect with emergency care providers instead of being referred to the emergency department (ED) following calls to a medical advice line. We used a staggered rollout design to assess the effects of implementing this program on key outcomes among Veterans Affairs enrollees. Analyzing over 1 million calls from 2019 to 2022, we found that access to a provider reduced the proportion of patients who subsequently visited the ED compared with those with access to the standard medical advice line (38% vs 36%). There was no significant difference observed in subsequent inpatient admissions or 30-day mortality. We found that a majority of callers (65%) achieved issue resolution or were directed to lower acuity settings for further evaluation. Although substantial direct cost savings were not evident, our findings demonstrate that on-demand access to a virtual provider can effectively decrease ED visits.

Payer shifting after expansions in access to private care among veterans.

To investigate whether expanded access to Veterans Affairs (VA)-purchased care increased overall utilization or induced a shift from other payers to VA for emergency care among VA enrollees. This study included all emergency department (ED) encounters in 2019 from hospitals in the state of New York. We conducted a difference-in-differences analysis comparing VA enrollees to the general population before and after the implementation of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in June 2019. We included all ED visits with individuals aged 30 or older at the time of the encounter. Individuals were considered eligible for the policy change if they were enrolled with VA at the beginning of 2019. Of the 5,577,199 ED visits in the sample, 4.9% (n = 253,799) were made by VA enrollees. Of these, 44.9% of visits were paid by Medicare, 32.8% occurred in VA facilities, and 7% were paid by private health insurance. There was a 6.4% (2.91 percentage points; std. error = 0.18; p < 0.01) decrease in the proportion of ED visits paid by Medicare among VA enrollees relative to the general population after the implementation of the MISSION Act in June 2019. This decrease was larger for ED visits with a subsequent inpatient admission (-8.4%; 4.87 percentage points; std. error = 0.33; p < 0.01). There was no statistically significant change in the total volume of ED visits (0.06%; std. error = 0.08; p = 0.45). Leveraging a novel dataset, we demonstrate that MISSION Act implementation coincided with a shift in the financing of non-VA ED visits from Medicare to VA without any increase in overall ED utilization. These findings have important implications for VA health care financing and delivery.

The Association Between Family Medicine Appointment Cancellations and Hospital Utilization in 2019 and 2020.

The COVID-19 pandemic caused a disruption in the usual primary care services offered and received by patients. The objective of this study was to compare the impact of family medicine appointment cancellations on hospital utilization metrics both before and during the COVID-19 pandemic within a family medicine residency clinic. This study is a retrospective chart review of cohorts of patients with a family medicine clinic cancellation who presented to the emergency department during a similar time period before and during the pandemic (March-May of 2019 vs March-May 2020). The patient population studied has multiple chronic diagnoses and prescriptions. Hospital admission, hospital readmission, and length of stay for hospitalizations during these periods were compared. The impacts of appointment cancellations on the emergency department presentation with subsequent inpatient admission, readmission, and length of stay were examined using generalized estimating equation (GEE) logistic or Poisson regression models to account for the lack of independence between patient outcomes. A total of 1878 patients were included in the final cohorts. Of these patients, 101 (5.7%) presented to the emergency department and/or hospital in both 2019 and 2020. An increased odds of readmission was associated with family medicine appointment cancellation regardless of year. The effects of appointment cancellations were not associated with admissions or length of stay between 2019 and 2020. Between the 2019 and 2020 cohorts, appointment cancellations were not associated with significant differences in likelihood of admission, readmission, or length of stay. A higher risk of readmission was associated with patients with a recent family medicine appointment cancellation.

Impact of a dedicated center for atrial fibrillation on resource utilization and costs.

Atrial fibrillation (AF) affects millions of Americans each year and can lead to high levels of resource utilization through emergency department (ED) visits and inpatient stays. We hypothesized that referral of patients to a dedicated Center for AF from the ED would reduce costs of care. The University of Pittsburgh Center for AF serves as a rapid referral center for patients with AF to avoid unnecessary inpatient admissions and provide specialized care. Patients that presented to the ED with AF and met prespecified criteria were directed to rapid outpatient follow-up instead of inpatient admission. The primary outcome of interest was 30-day total costs. Secondary outcomes included outpatient costs, inpatient costs, 90-day costs, and inpatient stay characteristics. We identified 96 patients (median age 65, 38% women) referred to the center for AF for a new diagnosis of AFbetween October 2017 and December 2019 and matched 96 control patients. After 30 days of follow-up, patients referred to the center for AF had a lower average cost ($619 vs. $1252, p < 0.001) compared to controls, driven by lower costs of ED care tempered by slightly higher outpatient costs. Thirty-day admissions and lengths of stay were also lower. These differences were persistent at 90 days. Directing patients with AF that present to the ED to follow-up at a dedicated Center for AF significantly reduced overall costs, while reducing subsequent inpatient admissions and total lengths of stay in the hospital.

Increasing incidence of pediatric mild traumatic brain injury in Finland – a nationwide register study from 1998 to 2018

AimThe purpose of this study is to document the annual incidence and incidence trends of pediatric traumatic brain injury (pTBI) in Finland over the course of 21 years. MethodsWe conducted a retrospective nationwide register-based cohort study and used the Finnish Care Register and Population information statistics from 1998 to 2018. The patient group includes all patients aged <18 at the time of injury. We included all emergency department (ED) visits and subsequent inpatient admissions (meaning at least one night in the hospital) with International Classification of Diseases diagnostic code S06*. We calculated pTBI incidences per 100,000 person-years with 95% confidence intervals and the incidences were compared by incidence rate ratios (IRR), including age, diagnosis, and gender stratified analyses. ResultsA total of 71,972 patients were included with 76,785 ED visits or hospitalizations for pTBI diagnoses. The annual incidence of diagnosed pTBI was 251 (CI: 241–260) per 100,000 in 1998 and 547 (CI: 533–561) per 100,000 in 2018, indicating a 118% increase in the incidence (IRR 2.18 CI: 2.09–2.28). Boys had 32% higher incidence (IRR 1.32 CI: 1.30–1.34) than girls. The highest cumulative incidence was observed among boys aged <1 years, 525 (CI: 507–543) per 100,000, and boys had higher incidences in all age groups. The most used diagnostic code was concussion, which included 92.1% of the diagnoses followed by diffuse brain injury, which included 2.3% of the diagnoses. The increase in the incidence of diagnosed pTBI was notably high after 2010. Concussion diagnoses and pTBI cases that were discharged directly from the ED had more than a two-fold increase from 2010 to 2018, whereas the incidence of inpatient admissions for pTBI increased by 53%. ConclusionsThe overall incidence of diagnosed pTBI has increased in Finland especially since 2010. Boys have higher incidence of diagnosed pTBI in all age groups. Most of the increase was due to increase in the concussion diagnoses, which may be due to the centralization of EDs into bigger units and increased diagnostic awareness of mild pTBI.

EGS P19 A new normal or the calm before the storm?

Abstract Background One of the highest risk factors for morbidity and mortality for general surgery patients is having their surgery in the emergent rather than elective setting. Patients are presenting older, with often complex pathology on a background of multiple medical comorbidities and sometimes extensive surgical history. NELA (national emergency laparotomy audit) and similar projects have looked at assessing and improving upon the management of such cases. These have produced valuable data and improvement in outcomes but there remains a lack of information around the acuity of surgery and the provision of services in response to demand. This study sought to assess the number of NELA cases in hospitals around the UK and compare this to historical data pre-pandemic. Methods Acute trusts admitting adults under general surgery in England were identified from the online NHS Service Directory. This list was cross referenced with the National Emergency Laparotomy Audit (NELA) list of participating hospitals to check for completeness. This generated 123 acute trusts in England. Contact details for each trust's Freedom of Information (FOI) department was identified from publicly available data on each trust's website. Questions were submitted to the FOI via email for 112 trusts, and online form submission for 11 trusts. Responses were collected for 8 weeks from the date of submission and analysed in Microsoft Excel. Trusts were asked to provide the number of general surgery admissions, inpatient bed numbers and NELA numbers. These were cross-referenced with publicly available data from NHS and NELA websites. Comparisons were made to similar data from 2014. Results 101 out of 124 trusts responded within the 8-week timeframe. 14,497 NELA cases were recorded from the national total of 21,846 stated in the NELA Year 7 report (66.36%). The mean number of beds reported per NELA case was 5.76 (+/- 1.46 CI 95%), with histogram peaking between 3 and 5 beds with a right skew distribution. The mean number of admissions per NELA case was 30.81 (+/- 3.29 CI 95%), with histogram data peaking between 21 and 26 admissions with right skew distribution. A comparison with data from 2014 can be seen below (table 1). Conclusions The Covid-19 pandemic had significant and widespread effects on the provision of services but also to demand. We now know that presentations to hospital reduced as did subsequent inpatient admissions. Our study shows that the number of NELA cases decreased across England and this was independent of hospital size. The largest decrease was seen in quartile 2 followed by quartile 3 representing mid-sized hospitals. Whilst not certain it is likely that this decrease was secondary to the pandemic rather than any change in practices. The results from this study can be used to help hospitals and departments plan their provision of services and training.

Health Care Resource Utilization and Costs of CAR T Therapy in Patients with Large B-Cell Lymphoma: A Retrospective US Claims Database Analysis

Introduction: Despite its association with promising clinical outcomes, chimeric antigen receptor T-cell (CAR T) therapy may not be a feasible treatment option for some patients with relapsed or refractory large B-cell lymphoma (LBCL). Although more patients have been referred to CAR T therapy in recent years, many patients are still not treated due to anticipated costs and logistical challenges, particularly in the community setting (Gajra et al, Immunotherapy 2020). Because of long manufacturing times, patients often require bridging therapy prior to CAR T and a subset of patients die on bridging therapy without ever receiving CAR T (Chow et al, Am J Hematol 2020). Furthermore, more than one-half of patients relapse within 1 year of receiving CAR T therapy (Spiegel et al, Blood 2021). It is important to understand the clinical and economic burden associated with CAR T therapy. We assessed health care resource utilization (HCRU) and all-cause health care (medical and medication) costs from 30 days prior to through 90 days after infusion with tisagenlecleucel or axicabtagene ciloleucel CAR T therapy in patients with diffuse large B-cell lymphoma (DLBCL), the most common non-Hodgkin lymphoma (NHL) subtype, or primary mediastinal large B-cell lymphoma (PMBCL), another aggressive NHL subtype. Methods: This observational, retrospective cohort study analyzed MarketScan (IBM, Armonk, NY) administrative claims data for adult patients with DLBCL and PMBCL who received CAR T infusion therapy between October 1, 2017 and March 31, 2021, and who had continuous enrollment 6 months before and at least 90 days after the CAR T treatment date (index date). Those with mantle cell lymphoma or follicular lymphoma were excluded. Hospital length of stay (LOS) and HCRU from 30-days prior to 90-days post-infusion for inpatient and outpatient hospital visits and other facility visits were examined. All-cause medical, medication, and health care costs per patient were reported in 2021 US dollars. Results: A total of 106 patients (DLBCL, n=92; PMBCL, n=14) who received CAR T therapy (mean age, 55 years; men, 59%; commercial payer, 87%; CAR T brand information available, n=20 patients) were included in the analysis. A majority of patients (78 [74%]) had at least 5 outpatient hospital visits in the 30 days prior to CAR T therapy. Many were reported as having received bridging and/or lymphodepletion treatment prior to CAR T infusion (81 [76%]). CAR T therapy was administered in an inpatient setting for 92 patients (87%) with a mean (SD) LOS of 18.4 (11.3) days and a mean (SD) cost of $341,217 ($245,564) within 90 days. Among those receiving CAR T inpatient, 41 (45%) had intensive care unit (ICU) admissions during their stay. In the 90 days post-CAR T infusion, most patients (92 [87%]) had at least 5 outpatient hospital visits. Subsequent inpatient admissions occurred in 30 patients (28%), with a mean (SD) LOS of 12 (12.44) days and a mean (SD) cost of $83,952 ($105,961) within 90 days after CAR T infusion. From 30 days prior to 90 days after infusion, the mean (SD) total all-cause health care costs per patient, including those associated with CAR T therapy, were $511,139 ($293,631) (Figure). Conclusions: While CAR T therapy may be a treatment option as LBCL patients progress, patients face a considerable clinical and economic burden. Both the HCRU prior to infusion and after infusion included frequent outpatient hospital visits. Additionally, in this analysis, inpatient hospitalizations were the primary driver of HCRU and costs of CAR T therapy. Most patients received CAR T therapy on an inpatient basis, requiring prolonged stays. Nearly half of patients were admitted to the ICU and more than a quarter experienced secondary inpatient stays. Costs associated with the logistically challenging CAR T therapy within a month leading up to the infusion and up to 3 months post-infusion are substantial, averaging half a million dollars per patient, indicating a significant burden, given that a majority of the patients relapse within a year. These findings underscore the need for an accessible, off-the-shelf, and efficacious therapeutic option for LBCL patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Emergency department utilization among skin cancer patients: a retrospective study of the national emergency department sample 2013-2015.

Skin cancer-related emergency department (ED) visits are among the most common cancer-related ED visits in the USA. However, ED utilization among skin cancer patients has not been evaluated. To assess overall utilization of EDs among skin cancer patients, reasons for skin cancer-related visits, and factors associated with inpatient admission. This was a retrospective, cross-sectional study of adults with skin cancer presenting to EDs using years 2013-2015 of the Nationwide Emergency Department Sample. In total, 693,835 of the 223,329,909 weighted ED visits were made by patients with skin cancer. Visits among this population were frequently due to age-related comorbidities and skin cancer treatment-specific adverse events. Melanoma accounted for the minority of skin cancer-related visits (27.58%), but over half of subsequent inpatient admissions (51.18%) and was associated with greater odds of inpatient admission compared to keratinocyte carcinoma (OR 1.278, 95% CI 1.264-1.293). Treatment and staging codes were not available, and thus, differences in ED utilization among skin cancer stages and treatment approaches could not be assessed. Ultimately, these findings are important in improving anticipatory outpatient care for patients with skin cancer and in guiding appropriate management of this unique population in the ED.

Real-world retrospective analysis of patient characteristics, healthcare resource utilization, costs, and treatment patterns among unvaccinated adults with COVID-19 diagnosed in outpatient settings in the United States

Aims This retrospective analysis of the Optum Clinformatics Data Mart database evaluated US patient characteristics, healthcare resource utilization (HCRU), costs, and treatment patterns among unvaccinated adults with outpatient-diagnosed COVID-19 to quantify US economic burden. Materials and methods The index event was the earliest outpatient diagnosis of confirmed COVID-19 from May 1 to December 10, 2020. Patients had 12 months’ continuous enrollment before and were followed for ≥60 days after index date until insurance dis-enrollment or study end. Results 236,589 patients had outpatient-diagnosed COVID-19 (7,692 with and 228,897 without subsequent COVID-19-related inpatient admission >48 h post-diagnosis). The median age was 51 years (≥65 years, 30.0%); 72.4% had ≥1 risk factor. Patients with versus without subsequent inpatient admission were more often male, older, Black/Hispanic, and had comorbidities/risk factors. With a median follow-up of 162 days, patients had a median of 1 COVID-19-related outpatient visit (with inpatient admission, 5 outpatient visits). Those with inpatient admission had a median of 1 COVID-19-related inpatient visit (median length of stay [LOS], 6 days), 33.3% were admitted to intensive care (median LOS, 8 days), 8.4%, 7.1%, and 13.3% received invasive mechanical ventilation, noninvasive mechanical ventilation, and supplemental oxygen, respectively; 13.5% experienced readmission. Inpatient mortality was 6.0% (0.3% for nonhospitalized patients). Antithrombotic therapy, antibiotics, corticosteroids, and remdesivir use increased among patients with inpatient admission versus without. Median total COVID-19-related non-zero medical costs were $208 for patients without inpatient admission (with inpatient admission, $39,187). Limitations Results reflect the circulating SARS-CoV-2 and treatment landscape during the study period. Requirements for continuous enrollment could have biased the population. Cost measurements may have included allowed (typically higher) and charge amounts. Conclusions Given the numbers of the US population who are still not fully vaccinated and the evolving epidemiology of the pandemic, this study provides relevant insights on real-world treatment patterns, HCRU, and the cost burden of outpatient-diagnosed COVID-19.

Utility of Temporal Bone Computed Tomography in Pediatric Emergency Medicine.

ObjectiveTemporal bone computed tomography (CT) requires a relatively high radiation dose to produce high-resolution images required to define surgical anatomy. In the acute setting, the need for this detailed evaluation of temporal bone pathology may not be required for nonsurgical management and clinical decision-making. We performed a retrospective review of the clinical characteristics and subsequent management of children who underwent CT of the temporal bone with the goal of optimizing clinical decision-making and mitigating the risks of radiation exposure in children.MethodsWe included pediatric patients (<18 years of age) with International Classification of Diseases (9th or 10th revision) diagnoses consistent with otitis externa, otitis media, mastoiditis, head trauma, temporal bone fracture, and otalgia who were treated in the emergency department and underwent temporal bone CT from January 1, 2012–December 31, 2016. We collected data regarding the patients’ presenting symptoms, physical exam findings, indications for imaging, radiographic findings, disposition, and operative intervention within 30 days of imaging. Features of the suspected mastoiditis group were compared between operative and non-operative patients.ResultsOver the four-year study period there were 96 temporal bone CTs. Most studies (70%) were associated with a subsequent inpatient admission. Common indications for imaging included evaluation of acute mastoiditis (55%) or trauma (41%). Of the 53 patients with concern for mastoiditis, 27 (51%) required otologic surgery. Two patients in the trauma group required surgical intervention, both for facial nerve decompression. In patients with suspected mastoiditis, mental status changes (P = 0.02), auricular proptosis (P = 0.05), and fluctuance (P = 0.02) were significantly more prevalent in the operative group; however, no other findings were significantly associated with operative intervention.ConclusionTemporal bone CT is beneficial in guiding diagnosis and management of acute mastoiditis. We found that a majority of patients with suspected mastoiditis who underwent temporal bone CT ultimately required surgery or hospital admission. However, the potential for reduction in the use of CT still exists in this population. Fractures of the temporal bone typically do not require urgent operative intervention in the absence of complete facial nerve paralysis; thus, the utility of temporal bone CT in trauma evaluation may be limited.

928. Clinical Characteristics and Microbiology Testing Patterns Among Transplant Recipients Admitted to Acute Care Hospitals for Suspected Infection

BackgroundSolid organ transplant (SOT) is a growing option for patients with end-stage organ diseases. Immunosuppressive therapy (IT) is utilized in this population to minimize risk of allograft rejection, which increases infection risk particularly of atypical pathogens that can complicate the infection-related diagnostic journey. The purpose of this analysis was to evaluate baseline clinical characteristics and microbiological testing utilization patterns among a cohort of patients with a history of SOT and IT.MethodsThis retrospective cohort study utilized a US hospital-based, service-level database. Patients were selected from a subsample of database facilities utilizing plasma microbial cell-free DNA diagnostic assays. The study period was 1/1/2017-3/21/2020. Eligible patients were identified by 1st observation of SOT status and IT. Subsequent inpatient admissions for suspected infection were analyzed.ResultsWe identified 749 patients with SOT history and use of IT, 56.4% were male, and the mean age was 52.8 (18.7) years. Kidney was the most prevalent transplant category (49.1%), followed by liver (14.1%), lung (10.9%), and heart (10.3%), and 9.7% were multi-organ. Patients experiencing multiple transplants had the most chronic conditions with a mean Elixhauser comorbidity score of 26.3 (14.7). The median length of stay was 4 [3-7] days. The median number of tests per encounter was 6 [IQR=3-11]. Culture was the most utilized test category (2 [1-4]). Blood culture was the highest utilized culture and overall test at 13.5% of all tests observed, while CMV PCR (7.8%) and multi-panel EIA (2.7%) were the most frequent molecular and antigen tests, respectively. Lung transplant recipients had the greatest utilization of tests overall (9 [3.5-17]) versus other transplant categories (6 [3-10]), consistent with the observed test rate in the 1st 48 hours of presentation (4 [1-7] vs. 2 [1-5]). ConclusionThis analysis suggests that the infection-related diagnostic journey among patients with a history of SOT involves high utilization of microbiological testing, with greater utilization among lung transplant recipients versus other SOT recipients. Variation in clinical characteristics and microbiological testing patterns were observed across SOT categories. Disclosures T Matthew Hill, PharmD, PhD, Karius, Inc (Employee, Shareholder) Erick R. Scott, MD, MHS, Karius, Inc (Employee, Shareholder) Sivan Bercovici, PhD, Karius (Employee)

Characteristics of patients hospitalized through the emergency department with an oncology drug-related side effect.

6557 Background: Recent advances in oncology treatment present an expanding spectrum of cancer-treatment-related emergencies.Many aspects of healthcare utilization, specifically emergency department (ED) visits, are not well studied in this population. The purpose of this study is to determine (1) what proportion of cancer patients visit the ED with an oncology drug-related side effect and are admitted and (2) what factors impact the probability of inpatient admission among these patients. Methods: This study evaluated ED visits by adult patients undergoing active drug treatment for cancer insured by a large commercial and Medicare health plan in the United States between January 1, 2018, and September 30, 2019. Among cancer-related ED visits, logistic regression was used to determine the marginal effect of demographic and clinical characteristics of patients on acute inpatient admission. Results: There were 39,921 total ED visits among patients undergoing drug treatment for cancer; of these, 76% presented with an oncology drug-related side-effect. 36% of all ED visits resulted in admission, 5% resulted in an observation stay. After adjusting, age was not a significant predictor of inpatient admission. Being male (p &lt; 0.01) and living in urban (p &lt; 0.01) or suburban (p &lt; 0.01) zip codes significantly increased the likelihood of admission. Patients with colorectal (p = 0.019), gastrointestinal (p &lt; 0.01), blood (p &lt; 0.01), lung (p &lt; 0.01), metastatic (p &lt; 0.01) cancers, or Hodgkin’s lymphoma (p &lt; 0.01) had significantly increased risk of admission. Patients with prostate (p &lt; 0.01) cancer had a significantly reduced risk of admission. The primary complaint upon presentation to the ED was the most important predictor of inpatient admission; sepsis, pneumonia, medical complications, white cell disorders, metastatic cancer, and fractures were all associated with a significantly higher (all p &lt; 0.001) risk of admission. Patients with comorbid heart failure (p &lt; 0.001), those taking ulcer medications (p &lt; 0.01), or inflammatory bowel disease (p = 0.03) had a significantly increased risk of admission. Results were consistent regardless of payer (Medicare or commercial health plan). Conclusions: This study identified cancer patients for whom acute inpatient admission from an ED presentation is more likely. Future studies identifying cancer patients who may be at risk of making an ED presentation based on demographic, clinical and disease-related characteristics are needed and may help inform targeted follow up of patients to mitigate potentially avoidable ED presentation and subsequent inpatient admission.

Comparison of cost and resource utilization between firearm injuries and motor vehicle collisions at pediatric hospitals.

Firearm injuries are converging with motor vehicle collisions (MVC) as the number one cause of death for children in the United States. Thus we examine differences in hospital cost and hospital resource utilization between motor vehicle and firearm injury. This retrospective, cross-sectional study compares hospital costs and resource utilization of motor vehicle and firearm-injured children aged 0 to 19years of age over a 5-year time frame (January 1, 2013-December 31, 2017) in 35 freestanding children's hospitals that submitted data to the Pediatric Health Information System. The primary outcome was hospital-adjusted comparative cost per patient presentation. Generalized linear mixed models were used to quantify the relationship between the type of injury and each outcome, adjusting for patient characteristics and hospital. There were 89,133 emergency department (ED) visits attributed to MVCs and 3,235 for firearm injury. Of the youths who presented for firearm injury, 49% were hospitalized versus 14% of youths presenting with MVC (adjusted odds ratio [aOR]= 6.6, 95% confidence interval [CI]= 6.1 to 7.2). Youths with firearm injury were more likely to be admitted to an intensive care unit (aOR= 6.7, 95% CI= 5.9 to 7.7) and had longer lengths of stays (aOR= 2.2, 95% CI= 1.9 to 2.6) compared to their MVC counterparts. Children admitted for firearm injury had more imaging and ED return visits, along with subsequent inpatient admission within 3 days (aOR= 3.4, 95% CI= 2.1 to 5.5) and 1year (aOR= 2.5, 95% CI= 2.1 to 2.9). The mean relative per-patient costs were nearly fivefold higher for the firearm-injured group. Hospital costs and markers of resource utilization were higher for youths with firearm injury compared to MVC. High medical resource utilization is one of several important reasons to advocate for a comparable national focus and funding on firearm-related injury prevention.

Trends in US emergency department visits and subsequent hospital admission among patients with inflammatory bowel disease presenting with abdominal pain: a real-world study from a national emergency department sample database

ABSTRACT Background/Objective: This study evaluated emergency department (ED) visit trends, subsequent inpatient admissions for patients with inflammatory bowel disease (IBD) diagnosis and IBD-related abdominal pain (AP), and hospital-level variation in inpatient admission rates in the USA (US). Methods: This population-based, cross-sectional study included data from Nationwide Emergency Department Sample (NEDS, 2006─2013) database. Patients ≥18 years of age with primary ED diagnosis of IBD/IBD-related AP were included. Variables included demographics, insurance information, household income, Quan-Charlson comorbidity score, ED discharge disposition, and length of hospital stay (2006, 2010, and 2013). Variation between hospitals using risk-adjusted admission ratio was estimated. Results: Annual ED visits for IBD/100,000 US population increased (30 in 2006 vs 42 in 2013, p = 0.09), subsequent admissions remained stable (20 in 2006 vs 23 in 2013, p = 0.52). ED visits for IBD-related AP increased by 71% (7 in 2006 vs 12 in 2013; p = 0.12), subsequent admissions were stable (0.50 in 2006 vs 0.58 in 2013; p = 0.88). Proportion of patients with subsequent hospitalization decreased (IBD: 65.7% to 55.7%; IBD-related AP: 6.9% to 4.9%). Variation in subsequent inpatient admissions was 1.42 (IBD) and 1.96 (IBD-related AP). Conclusions: An increase in annual ED visits was observed for patients with IBD and IBD-related AP; however, subsequent inpatient admission rate remained stable.

Guidelines for breast reconstruction during the COVID-19 pandemic: Are we considering enough evidence?

Guidelines for breast reconstruction during the COVID-19 pandemic: Are we considering enough evidence?

Unintentional Pediatric Poisoning Exposures in an Emergency Department: A Comparison of Poison Control Center Referrals and Caregiver Self-Referred Visits.

The purpose of this study is to describe the demographics and clinical characteristics of patients referred to a pediatric emergency department (ED) for unintentional poisoning exposures by a poison control center (PCC) compared with patients/caregivers who self-refer. The electronic data warehouse at a pediatric hospital was queried from October 1, 2014, to September 30, 2015, for unintentional poisoning-related ED visits and subsequent inpatient admissions. Eligible patients aged 18 years and younger were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes for pharmaceuticals, non-pharmaceuticalchemicals, fumes/vapors, foreign bodies, adverse food reactions, food poisoning, and bites/stings. Referral classification (PCC referral vs self-refer) was determined by PCC and hospital medical records.Descriptive statistics were used to characterize the patient demographics and ED visits by referral classification and age group. Simple and multiple logistic regression models examined the individual and combined impact of demographic and clinical characteristics on self-referral. Of the 705 patients identified, 84.4% presented as caregiver/self-referred compared with PCC-referred. As compared with those who self-referred, a higher percentage of patients who contacted the PCC before ED presentation were white (93.9% [89.4-98.2%] vs 83.8% [80.7-86.7%]) and had commercial insurance (62.7% [51.5-69.5%] vs 53.0% [48.9-57.0%]). Pharmaceutical (71.9%) and chemical (14.0%) exposures were the most common exposure types for PCC-referred patients whereas foreign bodies (54.3%) were the most common for self-referred patients. The largest predictors of self-referral were age, insurance, and exposure type. Among patients presenting at 1 pediatric ED, disparities with PCC utilization exist among age groups, racial identification, and poison exposure type. Educational outreach interventions are needed to ensure optimal use of the PCC services by patients, caregivers, and health care professionals.

Emergency Department Visits and Subsequent Hospital Admission Trends for Patients with Chest Pain and a History of Coronary Artery Disease.

IntroductionHospitalization is the largest component of health care spending in the United States. Most hospitalized patients first visit the emergency department (ED), where hospitalization decisions are made. Optimal utilization of hospital resources is critical for all stakeholders.MethodsWe performed a population-based, cross-sectional study evaluating ED visits and subsequent inpatient admissions for patients with coronary artery disease (CAD) and chest pain (CP) suggestive of CAD from 2006 to 2013 using the Nationwide Emergency Department Sample database weighted for national estimates. We analyzed trends using a generalized linear regression model with a Poisson distribution and Wald test.ResultsFrom 2006 to 2013, there was a 15% decrease in ED visits for CAD (p < 0.01), while ED visit rates for CP increased 31% (p < 0.01). Subsequent inpatient admission rates decreased 18% for CAD (p < 0.01) and 33% for CP (p < 0.01). Trends were not modified by patient and hospital strata.ConclusionED visits and subsequent inpatient admissions resulting from CAD decreased from 2006 to 2013. Patients with CP had a substantially higher number of ED visits, with a significant decline in inpatient admissions.