Total Encounters Research Articles

Longitudinal Assessment of T1 Mapping Trends Disease in Pediatric Patients With Heart Transplant.

Surveillance for heart transplant rejection by endomyocardial biopsy is invasive and may yield false negatives. T1 and T2 mapping from cardiac magnetic resonance can demonstrate elevations with rejection. We sought to evaluate longitudinal changes in T1 and T2 mapping in pediatric patients with heart transplant. A cohort study was performed of pediatric patients with heart transplant who underwent concurrent endomyocardial biopsy and cardiac magnetic resonance with T1 and T2 mapping from December 2019 to July 2024. Segmental values were measured and subsegmental elevations (ie, hotspots) were identified. Subjects were categorized as either treated rejection or no rejection. Peak and mean T1 and T2 values and number of hotspots at/between each time point for patient dyads were compared between the groups. A total of 21 subjects (7 treated rejection, 14 no rejection) with 68 total encounters met inclusion criteria. Peak and mean T1 values were higher in treated rejection patients during the rejection period and decreased with treatment (peak, 1086 versus 1052; mean, 1028 versus 1021), such that at last follow-up when their rejection had resolved, there was no significant difference in values when compared with no rejection patients (peak, 1066; mean, 1016). The number of T1 hotspots decreased after rejection treatment (2 versus 1). There were no changes in peak or mean T2 values in the treated rejection group despite treatment, and peak and mean T2 values were similar to patients with no rejection through last follow-up. Elevated T1 values and hotspots observed during cardiac allograft rejection decline in response to treatment. Cardiac magnetic resonance may serve as a noninvasive monitoring tool for the development and resolution of rejection, as well as the effectiveness of rejection therapy.

Epidemiology of Deep Venous Thrombosis Among United States Emergency Departments Over an Eight-Year Period.

Deep vein thrombosis (DVT) is a significant cause of morbidity and mortality worldwide, accounting for substantial healthcare utilization. However, as management strategies have evolved, there is a critical need for current data on incidence, admission rates, and medical management of DVT in the ED setting. This cross-sectional study analyzed ED presentations for DVT from 2016-2023 using the Cosmos database. Inclusion criteria comprised patients aged ≥18 years with an ICD-10 code for acute extremity DVT. Outcomes included incidence rates, admission rates, and anticoagulant prescriptions. Data were analyzed using descriptive statistics, and subgroup analyses were performed for upper and lower extremity DVTs. Out of 190,144,463 total ED encounters, DVT represented 368,044 cases (0.2%). Among these cases, 119,986 (32.6%) were admitted, with admission rates stable over the study period. Apixaban was the most prescribed anticoagulant (40.3%), followed by rivaroxaban (28.3%), enoxaparin (7.9%), warfarin (3.6%), and dabigatran (0.3%). Use of apixaban increased from 12.4% in 2016 to 56.2% in 2023. Lower extremity DVTs comprised 88.5% of cases, with a 32.1% admission rate, while upper extremity DVTs accounted for 11.7% of cases, with a 37.0% admission rate. This study provides a summary of DVT presentations and management in United States EDs over an eight52 year period. The findings highlight stable incidence rates, reduced admission rates compared to historical data, and a significant shift towards the use of DOACs, particularly apixaban, for outpatient management. These trends underscore the importance of evidence-based practices 54 and ongoing research to optimize DVT management and improve patient outcomes.

Diverticulitis evaluation and management among United States emergency departments over an eight-year period

IntroductionDiverticulitis is a common reason for presentation to the Emergency Department (ED). However, as imaging options, risk stratification tools, and antibiotic options have expanded, there is a need for current data on the changes in incidence, computed tomography (CT) performance, antibiotic usage, and disposition over time. MethodsThis was a cross-sectional study of ED patients with a diagnosis of diverticulitis from 1/1/2016 to 12/31/2023. Using the Epic Cosmos database, all ED visits for acute diverticulitis were identified using ICD-10 codes. Outcomes included total ED presentations for diverticulitis, admission rates, CTs performed, outpatient antibiotic prescriptions, and antibiotics administered in the ED for admitted patients. ResultsThere were 186,138,130 total ED encounters, with diverticulitis representing 927,326 (0.50 %). The rate of diverticulitis diagnosis increased from 0.40 % to 0.56 % over time. The admission rate declined over time from 33.6 % to 27.7 %, while the CT rate rose from 83.0 % to 92.6 %. Among those discharged, 90.4 % received an antibiotic, which remained consistent over time. Metronidazole (55.1 %) and ciprofloxacin (40.8 %) were the most commonly prescribed antibiotics, followed by amoxicillin-clavulanate (36.1 %). Among those admitted, most received either metronidazole (62.0 %), a fluoroquinolone (40.4 %), a third-generation cephalosporin (18.9 %), or a penicillin-based agent (38.1 %). Among both discharged and admitted patients, there was a marked shift to penicillin-based agents as the primary antibiotic regimen. ConclusionDiverticulitis remains a common ED presentation, with a gradually rising incidence over time. Admission rates have decreased, while CT imaging has become more common. Most patients receive antibiotics, though the specific antibiotic has shifted in favor of penicillin-based agents. These findings can provide key benchmarking data and inform future initiatives to guide imaging and antibiotic use.

Single-center retrospective review of standard versus minimal monitoring for hepatitis C direct-acting antiviral therapy

BackgroundHighly effective direct-acting antiviral (DAA) therapies have transformed the landscape of hepatitis C virus (HCV) treatment. However, there continues to be limited data regarding the efficacy and safety of required in-person clinic visits (standard monitoring) versus completely telehealth clinic visits (minimal monitoring) during HCV therapy, which could delay practice adoption. ObjectivesThis study aimed to assess the rates of undetectable HCV ribonucleic acid (RNA) in sustained viral load 12 weeks after therapy (SVR12) in standard versus minimal monitoring approaches during DAA. MethodsA 12-month, single-center retrospective cohort study was conducted in treatment-naïve HCV-infected adults who received DAA therapy between May 1, 2020, and April 30, 2021. The standard monitoring group had ≥1 in-person clinic visit with HCV RNA laboratory monitoring during DAA treatment. The minimal monitoring group had entirely telehealth visits without HCV RNA laboratory monitoring during treatment. Both groups received telephonic touchpoints throughout DAA treatment from a clinical pharmacist practitioner and a nurse care coordinator. The primary outcome was SVR12. ResultsFrom May 2020 to April 2021, 133 patients with HCV met inclusion criteria and were treated with DAA (standard, n = 56; minimal, n = 77), with no differences in baseline demographics. Overall, total encounters during DAA treatment remained significantly higher in the standard than minimal monitoring group (standard, 2.1 ± 0.8, vs. minimal, 1.7 ± 0.9; P < .01). Although minimal monitoring had higher loss to follow-up rates (standard, 7.1%, vs. minimal, 18.2%; P = 0.06), the modified intention-to-treat analysis showed no differences in sustained virologic response (SVR) between standard and minimal monitoring approaches (standard, 98.1%, n = 51, vs. minimal, 95.3%, n = 60; P = 0.41). ConclusionsThis single-center retrospective cohort study demonstrated that minimal monitoring during HCV treatment was as effective in achieving SVR cure rates as standard monitoring. Eliminating required in-person clinic visits during DAA therapy alongside a collaborative approach may play a major role in overcoming barriers to HCV care in select patients.

Respiratory Syncytial Virus and US Pediatric Intensive Care Utilization

Bronchiolitis is the most common diagnosis necessitating respiratory support and pediatric intensive care, and respiratory syncytial virus (RSV) is the most common cause of bronchiolitis. In 2023, the monoclonal antibody nirsevimab and the maternal RSVpreF vaccine were implemented to prevent RSV in infants. To determine the potential association of novel RSV prevention strategies with pediatric intensive care unit (ICU) utilization. This retrospective cross-sectional study examined US pediatric ICU encounters with and without RSV from January 1, 2017, to June 1, 2023. Data were from Oracle Cerner RealWorld Data, a national electronic health record database. All children (aged >1 day and <18 years) admitted to an ICU during the study period were included in the analysis. Statistical analysis was performed from February to May 2024. The primary outcomes were ICU encounters with RSV and ICU encounters with RSV eligible for RSV prevention. There were 119 782 ICU encounters from 53 hospitals; 65 757 encounters (54.9%) were male; median (IQR) age was 4.5 (1.1-12.5) years, median (IQR) ICU length of stay was 1.8 (1.0-3.9) days; 13 702 ICU encounters (11.4%) had RSV, of which 38.6% (5217) were eligible for prevention (4.4% of total ICU encounters). Encounters with RSV accounted for 21.1% (109 334) of ICU days, of which 43.8% (47 888) were eligible for prevention (9.2% of total ICU days). Encounters with RSV were associated with a greater use of positive pressure ventilation (4074 [29.7%] vs 18 821 [17.7%]; P < .001) and vasoactive medications (3057 [22.3%] vs 18 570 [17.5%]; P < .001) compared with those without RSV. The findings of this retrospective cross-sectional study of RSV and US pediatric intensive care utilization suggest that if 65% to 85% of eligible children received RSV prevention, an estimated 2.1% to 2.8% reduction in pediatric ICU encounters and an estimated 4.5% to 5.9% reduction in pediatric ICU days could be achieved.

Otolaryngology Diagnoses at a Student-Run Community Clinic.

Purpose Compared to insured individuals who have established pathways for primary and specialist care, uninsured patients often delay seeking medical attention and are more likely to rely on emergency departments or community clinics for low-cost services. This study aims to identify the most prevalent otolaryngology (ENT) diagnoses at a free, student-run community clinic for uninsured patients. Additionally, it seeks to elucidate their management needs in order to inform strategies for enhancing support and care for this vulnerable population. Methods The electronic medical records for a free, student-run community clinic (St. Vincent's Hope Student Clinic in Galveston, Texas) were reviewed. Patient age, sex, chief complaint, date of medical encounter, and encounter diagnoses from April 2021 to May 2024 were recorded; medical diagnoses were then manually stratified into system categories and diagnostic subgroups. Diagnoses unrelated to ENT were excluded and likely represented secondary encounter diagnoses. Results A total of 38 patients were evaluated across 51 total ENT encounters. The average number of encounters per patient per year was 1.34 (1.05-1.63, 95% CI). The most common ENT category was throat (37%), and the most common individual diagnosis was balance problems (11% of total diagnoses). Conclusion The most common ENT system was the throat, followed by ear, nose, and other. Balance problems, reflux, and allergic rhinitis were the most common individual ENT diagnoses. The analysis of data collected for this study may help direct future care and resource allocation at this clinic.

Epidemiology of pulmonary embolism diagnosis and management among United States emergency departments over an eight-year period

IntroductionPulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. However, as diagnostic imaging, risk stratification tools, and treatment have evolved over time, there is a critical need for current data on the incidence, testing, admission rates, and medical management of PE in the ED setting. MethodsThis was a cross-sectional study of ED patients with PE diagnoses from 1/1/2016 to 12/31/2023 using the Epic Cosmos national database. ED visits were identified using ICD-10 codes corresponding to acute PE. Chronic PEs were excluded. Outcomes included total ED visits, admission rates, anticoagulant treatment prescribed from the ED, and thrombolytic therapy. Anticoagulant prescriptions included warfarin, enoxaparin, dabigatran, apixaban, rivaroxaban, edoxaban, and betrixaban. Thrombolytic agents included alteplase, tenecteplase, and urokinase. We also assessed changes in the overall rate of CT pulmonary angiograms (CTPA) performed. ResultsOut of 186,138,130 total ED encounters, PE represented 531,968 (0.29 %). The overall rate of PE diagnosis rose slowly from 0.20 % in 2016 to a peak of 0.35 % in 2021. Among those with PE, 363,584 (68.3 %) were admitted. The rate of admission declined over time from 75.6 % to 66.1 %. Among those prescribed anticoagulation, the most common medication was apixaban (40.0 %), followed by rivaroxaban (17.3 %), enoxaparin (6.1 %), warfarin (2.6 %), and dabigatran (0.4 %). Thrombolytics were administered in 4.5 % of cases, with the rate of thrombolytics peaking at 5.3 % in 2018 before lowering to 3.5 % in 2023. The overall rate of CTPA increased from 2.4 % to 5.0 %, while the rate of proportion of PEs diagnosed declined from 8.7 % to 6.4 %. ConclusionThis study highlights significant shifts in the epidemiology and management of PE within the ED setting. Overall rates of PE rose, while a larger proportion were discharged. Direct oral anticoagulants have become the predominant therapy with the majority of patients receiving apixaban. Thrombolytic use occurs in a small subset and has been declining over time. CTPA rates have risen, while the overall diagnostic yield has declined.

Characterising practice patterns of human derived, lyophilized coagulation concentrates within the trauma quality improvement program registry.

We seek to describe the current practice pattern use of prothrombin complex concentrate (PCC) and fibrinogen concentrate (FC) in trauma patients. Trauma-induced coagulopathy (TIC) and endotheliopathy of trauma (EOT) contribute significantly to mortality from traumatic haemorrhage. FC, and 4-factor PCC are potential treatments for EOT and TIC, respectively. We obtained data from the Trauma Quality Improvement Program (TQIP) registry and identified patients who received either PCC or FC using procedural codes. We used descriptive statistics to characterise practice patterns of these products. There were 6 714 002 total encounters within the TQIP from 2017 to 2022, of which 10 589 received PCC and 3009 received FC. Of the recipients, there were 35 that received both products. There were 44 that received both. The median age of PCC recipients was 77 (69-84) with 19 patients <15 years of age with the youngest being 2 years of age. There was a general upward trend in the number of facilities with documented use of PCC: 155/744, 168/766, 189/764, 206/780, 234/795, and 235/816, respectively. The median age of FC recipients was 57 (32-75) with 48 patients <15 years of age with the youngest being 1 year of age. There was a minor downward trend in the number of facilities that had documented use of FC: 55, 44, 39, 32, 38 and 40. The administration of PCC and FC remains uncommon, although there appears to be an upward trend of PCC use. Most PCC use appeared to be for anticoagulation reversal in the setting of head trauma. Data guiding the use of these products are necessary as these products become more recognised as adjuncts to traumatic haemorrhage control.

Better Care, Same Cost - Reducing Unplanned Care for Multi-visit Patients: A Payer-Provider Model.

Many interventions implemented for multi-visit patients (MVP) have been developed to address patient-centric needs of these individuals and reduce unplanned care for ambulatory-sensitive conditions. More rigorous research is needed to better understand the impact of these interventions on changes in care utilization including unplanned care. To evaluate the impact of the Enhanced Care Program (ECP), a payer-provider collaborative model, on unplanned care use and cost of care. Using propensity methods, a comparison group was constructed using insurer membership files. Comparisons were performed using a difference-in-differences analysis. Patients enrolled in ECP through December 2019 were considered eligible for the study (n = 357). All patients had five or more ED visits in the past year or two or more inpatient hospitalizations in the past year prior to enrollment. ECP is a high-intensity outpatient intervention intended to reduce avoidable unplanned care such as ED visits and inpatient hospital stays through home visits, chronic/acute disease management, and intensive care coordination. The primary outcomes of interest were events per 100 members per year of ED use with return to home, unplanned inpatient and observational status admissions, and unplanned behavioral health inpatient admission, and cost of care per member per month. Overall total unplanned care encounters were significantly reduced with a difference-in-difference of 320 unplanned care encounters per 100 members per year in the intervention group (p < 0.05). The ECP group showed statistically significant decreases in costs of unplanned ED, unplanned observation admission, and unplanned inpatient behavioral medicine costs, but statistically significant increases in overall pharmacy costs and lab costs. Changes in total costs of care for the ECP group were not statistically different than the control group (p = 0.55). ECP showed significant reduction of unplanned care for MVP patients.

Closing the gap: addressing telehealth disparities across specialties in the sustained pandemic era

Missed appointments, or no-shows, disrupt healthcare delivery, exacerbating chronic disease management and leading to worse health outcomes. Telehealth has surged as a viable solution to reduce no-shows and improve healthcare accessibility, especially during the COVID-19 pandemic. However, telehealth disparities and its long-term efficacy across various medical specialties remain understudied. To address this, we performed a retrospective analysis of electronic health records from a heterogenous network of hospitals in Illinois, examining telehealth use and no-shows across among 444,752 adult patients with 1,973,098 outpatient encounters across nine specialties during the sustained pandemic phase (i.e., January 1, 2021 to July 1, 2022). Among them, 84,290 (4.27%) were no-shows, and telehealth constituted 202,933 (10.3%) of the total encounters. Telehealth use during the sustained phase varied significantly by specialty type. Overall, telehealth encounters were associated with reduced no-show odds compared to in-person encounters (OR, 0.28; 95% CI, 0.26–0.29). Black and Hispanic patients, as well as those with Medicaid, had higher no-show odds relative to their counterparts, even when using telehealth. Mental health specialty had the highest telehealth usage rate and the highest no-show odds (OR, 2.99; 95% CI, 2.84–3.14) relative to other specialties included in the study. Moreover, specialty type had differential effects on no-shows for telehealth. These results underscore the variability in telehealth use by specialty type and pervasive disparities telehealth use and no-shows. As we move beyond the pandemic, our findings can inform policymakers to tailor policies and incentives to reach different patient groups as well as specialties, with varying needs, to promote equitable telehealth utilization.

Impact of the COVID-19 Pandemic on the Delivery of Congenital Syphilis Care in the Military Health System.

Congenital syphilis (CS) case rates have increased significantly in the United States over the past 20 years, accelerating during the COVID-19 pandemic. Increasing rates may relate to access to care but have not been evaluated in a fully-insured population, such as the Military Health System. We performed a repeated monthly cross-sectional study of CS cases and total encounters (care rates) using the queried Military Health System database. We defined CS by International Classifications of Diseases 10th Revision Clinical Modification diagnosis codes in beneficiaries ≤ 2 years old. We evaluated pre-COVID-19 (March 2018 to February 2020), pandemic year 1 (March 2020 to February 2021), and pandemic year 2 (March 2021 to February 2022) periods. We performed change-point and trend analyses and Poisson regression to evaluate differences by sponsor rank, TRICARE region, and pandemic period. The Uniformed Services University Institutional Review Board approved the study. A total of 69 unique CS cases were identified with a median monthly care rate of 0.90/100,000 eligible beneficiaries. The CS care rate showed a 5.8% average monthly percent increase throughout the study period (P < .001) and a 20.8% average monthly percent increase in year 2 (P < .05). Compared to the pre-pandemic era, CS care rates increased in pandemic years 1 and 2 (adjusted rate ratio [aRR] 2.76 [95% CI: 1.95-3.92], 5.52 [95% CI: 4.05-7.53], respectively). Congenital syphilis care rates were lower in children of senior enlisted sponsors versus junior enlisted, aRR 0.24 (95% CI: 0.17-0.33), and higher in the West and North regions versus South, aRR 2.45 (95% CI: 1.71-3.53) and aRR 2.88 (95% CI: 2.01-4.12), respectively. Congenital syphilis care rates were substantially lower in this insured group than national rates but increased significantly during the COVID-19 pandemic. Higher care rates were seen in children of military members of lower rank. Regional trends differed from national data. These findings suggest that, even in a fully-insured population, income and regional differences impact CS, and the COVID-19 pandemic may have exacerbated differences in care delivery.

U.S. trends in methamphetamine-involved psychiatric hospitalizations in the United States, 2015–2019

BackgroundIn the U.S., overdose deaths and substance treatment admissions related to methamphetamine are rising. This study aims to measure and compare U.S. temporal trends in methamphetamine-involved psychiatric hospitalizations. MethodsWe conducted a population-based, trend analysis of U.S. psychiatric hospitalizations and calculated quarterly (Q) rates per 100,000 population of substance-involved psychiatric hospitalizations. We assessed U.S. regional quarterly percentage hospitalization rate changes using Joinpoint regression. ResultsFrom Q4 2015-Q4 2019, there were 963,202 psychiatric hospitalizations, 50,223 (5.2 %) involved methamphetamine and 102,877 (10.7 %) involved opioids and/or cocaine without methamphetamine. Methamphetamine-involved psychiatric hospitalization rates increased by 68.0 %, psychiatric hospitalizations rates involving opioid and/or cocaine without methamphetamine decreased by 22 %, while nonsubstance-involved psychiatric hospitalizations rates remained unchanged. The largest significant increases in methamphetamine-involved psychiatric hospitalization rates were among people >61 years old, males, and Midwesterners. Methamphetamine-involved psychiatric hospitalization rates doubled among Black patients. The largest average percent increase among methamphetamine-involved psychiatric hospitalizations was 10.2 % from Q4 2015-Q2 2017 in the Midwest. Conclusion and relevanceMost psychiatric hospitalizations did not involve substances. Methamphetamine-involved psychiatric hospitalizations greatly increased while opioid-involved psychiatric hospitalizations decreased, but involved more total encounters. Greater access to harm reduction services, contingency management programs, and mental health services is urgently needed.

Impact of Clinical Practice Guidelines on Pediatric Tonsillectomy for Tonsillitis.

To determine the impact of the release of updated American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) Clinical Practice Guidelines (CPG) for Tonsillectomy in Children in 2019 on adherence to evidence-based practice. Patients between ages 1 and 18 who had tonsillectomies and encounters for throat infection (tonsillitis or pharyngitis) between of February 5, 2015 and February 4, 2023 were identified by International Classification of Diseases and Current Procedural Terminology codes, excluding those with obstructive sleep-disordered breathing. Retrospective chart review was performed to determine adherence to evidence-based practice. There was a significant increase in adherence to evidence-based practice post-CPG release compared to pre-CPG (85.4% vs 73.1%, P = .0088). There was an observed trend for improved adherence to evidence-based practice for pediatric tonsillectomy for recurrent infection for most of the post-CPG period. There were fewer tonsillectomies performed post-CPG, despite more total encounters for throat infection. The publication of the updated AAO-HNSF CPG corresponded with improved adherence to evidence-based practice for tonsillectomy in children for recurrent infection and an observed decrease in overall rate of tonsillectomy. This suggests the CPG may be an effective quality improvement tool for reducing variation and unnecessary patient morbidity or harm. These findings suggest that the updated AAO-HNSF CPG for Tonsillectomy in Children may have effectively impacted practice patterns, and further work should be done to expand their reach to other specialties and settings. Consideration should also be given to further understand any balancing factors associated with reduced tonsillectomies for recurrent infections including quality of life impact on children managed expectantly.

A Monte Carlo resampling framework for implementing goodness‐of‐fit tests in spatial capture‐recapture models

Abstract Spatial capture‐recapture (SCR) models provide estimates of animal density from spatially referenced encounter data and has become the most widely adopted approach for estimating density. Despite the rapid growth in the development and application of spatial capture‐recapture methods, approaches for assessing model fit have received very little attention when compared to other classes of hierarchical models in ecology. Here, we develop an approach for testing goodness‐of‐fit (GoF) for frequentist SCR models using Monte Carlo simulations. We derive probability distributions of activity centres from the fitted model. From these, we calculate the expected encounters in the capture history based on the SCR parameter estimates, propagating the uncertainty of the estimates and the activity centre locations via Monte Carlo simulations. Aggregating these test statistics result in count data, allowing us to test fit with Freeman‐Tukey tests. These tests are based on summary statistics of the total encounters of each individual at each trap (FT‐ind‐trap), total encounters of each individual (FT‐individuals) and total encounters at each trap (FT‐traps). We assess the ability of these GoF tests to diagnose lack of fit under a range of assumption violating scenarios. FT‐traps had the strongest response to unmodelled spatial and trap heterogeneity in detection probability (power = 0.53–0.56), while FT‐ind‐traps had the strongest responses to random individual variation in detectability (power = 0.88) and non‐spatial discrete variation in (power = 0.35). The tests, designed to diagnose poor fit in the detection parameters, were insensitive to unmodelled heterogeneity in density (power = &lt;0.001). They also demonstrated low false positive rates (&lt;0.001) when the correct models were fitted; therefore, it is very unlikely that they will provide false indications of poor model fit. We demonstrate that these GoF tests are capable of detecting lack‐of‐fit when unmodelled heterogeneity is present in the detection sub‐model. When used jointly, the combinations of test results are also able to infer the type of lack‐of‐fit in certain cases. Our Monte Carlo sampling methods may be extended to a wider range of GoF tests, thereby providing a platform for developing more GoF methods for SCR.

Using quality improvement frameworks to develop, implement, and evaluate a novel ambulatory oncology pharmacy practice model: A descriptive example.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. To describe the application of the Plan-Do-Study-Act quality improvement framework in the development, implementation, and evaluation of a novel pharmacy practice model in ambulatory oncology. Four iterations of the Plan-Do-Study-Act framework were completed to develop a patient-facing, pharmacist-led ambulatory oncology clinic program. The clinic provided care to patients with prostate cancer on oral anticancer therapy. Metrics were collected throughout all stages of development to inform target processes for improvement. The pharmacist saw 136 patients between July 2019 and January 2023, resulting in 464 total encounters. The pharmacist provided clinical interventions and counseling to patients newly starting on oral anticancer therapy and those established on therapy using a longitudinal model of care. Application of the Plan-Do-Study-Act quality improvement framework to a novel pharmacy practice model supported the development, evaluation, and sustainability of a pharmacist-led ambulatory oncology clinic providing care to patients with prostate cancer on oral anticancer therapy.

Toward Standardization and High Reliability: Improved Sepsis Screening in Emergency Department Triage Across an Academic Health System

Sepsis is a life-threatening emergency, and early recognition and treatment in the emergency department (ED) is critical to improving outcomes. The authors implemented an interdisciplinary quality improvement (QI) project to standardize sepsis screening workflow across an academic health system consisting of a large tertiary care urban hospital, one freestanding ED, and two small rural affiliate hospitals (RA-1 and RA-2). The research team used the Institute for Healthcare Improvement Model for Improvement framework, consisting of iterative Plan-Do-Study-Act (PDSA) cycles. The primary outcome was rates of screening for sepsis at each site. Secondary outcomes included sepsis mortality and Centers for Medicare & Medicaid Services (CMS) sepsis bundle (SEP-1) compliance at our main medical center. Primary outcome was assessed using electronic dashboards extracting the ratio of ED encounters with electronic health record (EHR)-documented sepsis screening per total ED encounters. The SEP-1 bundle was assessed as percent compliance, and mortality was calculated as average observed to expected (O:E). Averages were compared from preintervention to after initiating improvements using two-tailed t-tests. This QI project took place from December 2022 to December 2023 across four EDs that experience around 138,000 visits annually. A standardized workflow was established at ED triage with an EHR-based question and an associated nurse and physician defined response. Preintervention (October 2022 to November 2022) triage rates for sepsis were 1.7% (163/9,560), 25.3% (523/2,068), 11.0% (360/3,272), and 36.5% (915/2,506) at our main hospital, freestanding ED, RA-1, and RA-2, respectively. After four PDSA cycles, triage rates rose to 91.9% (4,927/5,360), 97.5% (1,032/1,059), 99.0% (1,845/1,863), and 97.4% (1,328/1,363), respectively (p < 0.005). Sepsis triage rates rose most slowly at the large academic medical center, where progressive PDSA cycles were needed to achieve > 90% screening for sepsis. Mean O:E mortality was 0.99 for the 9 months of available data preintervention and 0.83 in the 17 months postintervention (p = 0.07). CMS sepsis bundle compliance was 28.4% for the 15 months preintervention and 40.5% in the 17 months postintervention, (p = 0.14). An interdisciplinary QI project leveraged EHR optimization to integrate with human workflows over four PDSA cycles to achieve standardized and improved screening for sepsis in the ED. This resulted in lower sepsis mortality and increased sepsis bundle compliance, though results were not statistically significant.

Comparison of emergency medical services and emergency department encounter trends for nonfatal opioid-involved overdoses, nine states, United States, 2020–2022

BackgroundOpioid-involved overdoses, especially those involving synthetic opioids like fentanyl, have driven increases in overdose morbidity and mortality. Emergency medical services (EMS) and emergency department (ED) data can each provide near real-time information on trends in nonfatal opioid-involved overdoses; however, minimal data exist on the comparability of trends in these two data sources. MethodsEMS data from biospatial© and ED data from CDC’s Drug Overdose Surveillance and Epidemiology system and National Syndromic Surveillance Program were queried for nine states. Counts of total encounters, opioid-involved overdose encounters, and rates of opioid-involved overdoses per 10,000 total encounters were calculated for each data source from 2020 to 2022. Trends in monthly counts and rates were assessed using Joinpoint regression. ResultsOn average, EMS data captured 1.8 times more monthly opioid-involved overdose encounters than ED data. Trends in the counts of opioid-involved overdose encounters were similar in both data sources with increases and decreases occurring during roughly the same periods. Overall, trends in rates of opioid-involved overdose encounters were also comparable. ConclusionsEMS and ED data provide complementary information for understanding overdose trends. Study findings underscore the importance of implementing post-overdose response protocols by both EMS and ED providers to ensure patients receive services irrespective of care setting.

Cost effectiveness of commercial portable exvivo lung perfusion at a low-volume US lung transplant center.

Portable exvivo lung perfusion during lung transplantation is a resource-intensive technology. In light of its increasing use, we evaluated the cost-effectiveness of exvivo lung perfusion at a low-volume lung transplant center in the USA. Patients listed for lung transplantation (2015-2021) in the United Network for Organ Sharing database were included. Quality-of-life was approximated by Karnofsky Performance Status scores 1-year post-transplant. Total transplantation encounter and 1-year follow-up costs accrued by our academic center for patients listed from 2018 to 2021 were obtained. Cost-effectiveness was calculated by evaluating the number of patients attaining various Karnofsky scores relative to cost. Of the 13 930 adult patients who underwent lung transplant in the United Network for Organ Sharing database, 13 477 (96.7%) used static cold storage and 453 (3.3%) used exvivo lung perfusion, compared to 30/58 (51.7%) and 28/58 (48.3%), respectively, at our center. Compared to static cold storage, median total costs at 1 year were higher for exvivo lung perfusion ($918 000 vs. $516 000; p = 0.007) along with the cost of living 1 year with a Karnofsky functional status of 100 after transplant ($1 290 000 vs. $841 000). In simulated scenarios, each Karnofsky-adjusted life year gained by exvivo lung perfusion was 1.00-1.72 times more expensive. Portable exvivo lung perfusion is not currently cost-effective at a low-volume transplant centers in the USA, being 1.53 times more expensive per Karnofsky-adjusted life year. Improving donor lung and/or recipient biology during exvivo lung perfusion may improve its utility for routine transplantation.

Emergency Medical Services Encounters for Firearm Injuries - 858 Counties, United States, January 2019-September 2023.

Firearm-related deaths and injuries have increased in recent years. Comprehensive and timely information on firearm injuries and the communities and geographic locations most affected by firearm violence is crucial for guiding prevention activities. However, traditional surveillance systems for firearm injury, which are mostly based on hospital encounters and mortality-related data, often lack information on the location where the shooting occurred. This study examined annual and monthly rates of emergency medical services (EMS) encounters for firearm injury per 100,000 total EMS encounters during January 2019-September 2023 in 858 counties in 27 states, by patient characteristics and characteristics of the counties where the injuries occurred. Overall, annual rates of firearm injury EMS encounters per 100,000 total EMS encounters ranged from 222.7 in 2019 to 294.9 in 2020; rates remained above prepandemic levels through 2023. Rates were consistently higher among males than females. Rates stratified by race and ethnicity were highest among non-Hispanic Black or African American persons; rates stratified by age group were highest among persons aged 15-24 years. The greatest percentage increases in annual rates occurred in urban counties and in counties with higher prevalence of severe housing problems, higher income inequality ratios, and higher rates of unemployment. States and communities can use the timely and location-specific data in EMS records to develop and implement comprehensive firearm injury prevention strategies to address the economic, social, and physical conditions that contribute to the risk for violence, including improvements to physical environments, secure firearm storage, and strengthened social and economic supports.

Remote Monitoring App for Endocrine Therapy Adherence Among Patients With Early-Stage Breast Cancer

Adjuvant endocrine therapy (AET) use among women with early-stage, hormone receptor-positive breast cancer reduces the risk of cancer recurrence, but its adverse symptoms contribute to lower adherence. To test whether remote monitoring of symptoms and treatment adherence with or without tailored text messages improves outcomes among women with breast cancer who are prescribed AET. This nonblinded, randomized clinical trial (RCT) following intention-to-treat principles included English-speaking women with early-stage breast cancer prescribed AET at a large cancer center with 14 clinics across 3 states from November 15, 2018, to June 11, 2021. All participants had a mobile device with a data plan and an email address and were asked to use an electronic pillbox to monitor AET adherence and to complete surveys at enrollment and 1 year. Participants were randomized into 3 groups: (1) an app group, in which participants received instructions for and access to the study adherence and symptom monitoring app for 6 months; (2) an app plus feedback group, in which participants received additional weekly text messages about managing symptoms, adherence, and communication; or (3) an enhanced usual care (EUC) group. App-reported missed doses, increases in symptoms, and occurrence of severe symptoms triggered follow-ups from the oncology team. The primary outcome was 1-year, electronic pillbox-captured AET adherence. Secondary outcomes included symptom management abstracted from the medical record, as well as patient-reported health care utilization, symptom burden, quality of life, physician communication, and self-efficacy for managing symptoms. Among 304 female participants randomized (app group, 98; app plus feedback group, 102; EUC group, 104), the mean (SD) age was 58.6 (10.8) years (median, 60 years; range, 31-83 years), and 60 (19.7%) had an educational level of high school diploma or less. The study completion rate was 87.5% (266 participants). There were no statistically significant differences by treatment group in AET adherence (primary outcome): 76.6% for EUC, 73.4% for the app group (difference vs EUC, -3.3%; 95% CI, -11.4% to 4.9%; P = .43), and 70.9% for the app plus feedback group (difference vs EUC, -5.7%; 95% CI, -13.8% to 2.4%; P = .17). At the 1-year follow-up, app plus feedback participants had fewer total health care encounters (adjusted difference, -1.23; 95% CI, -2.03 to -0.43; P = .003), including high-cost encounters (adjusted difference, -0.40; 95% CI, -0.67 to -0.14; P = .003), and office visits (adjusted difference, -0.82; 95% CI, -1.54 to -0.09; P = .03) over the previous 6 months compared with EUC participants. This RCT found that a remote monitoring app with alerts to the patient's care team and tailored text messages to patients did not improve AET adherence among women with early-stage breast cancer; however, it reduced overall and high-cost health care encounters and office visits without affecting quality of life. ClinicalTrials.gov Identifier: NCT03592771.