Total Outpatient Visits Research Articles

Interactive Effects between Temperature and Humidity on Outpatient Visits of Respiratory Diseases in Lanzhou, China

AbstractThis study assessing the lag and interactive effects between the daily average temperature and relative humidity on respiratory disease (RD) morbidity in Lanzhou, China, using data from daily outpatient visits for RD between 2014 and 2017 and meteorological and pollutant data during the same period analyzed with Poisson generalized linear model and distributed lag nonlinear models; the effects are further explored by classifying the RD by gender, age, and disease type. The results showed that the effect of temperature and relative humidity on outpatient visits of different populations and types of RD is nonlinear, with a significant lag effect. Relative to 11°C, every 1°C decrease in temperature is associated with 10.98% [95% confidence interval (CI): 9.87%–12.11%] increase for total RD. Chronic obstructive pulmonary disease is affected only by low temperature, upper respiratory tract infection is affected by both low and high temperatures, and asthma is influenced by high temperature. When the relative humidity is less than 32%, every 1% decrease in relative humidity is associated with 6.00% (95% CI: 3.00%–9.11%) increase for total RD; relative humidity has different effects on the outpatient risk of different types of RD. Temperature and relative humidity have an obvious interactive effect on different types and populations of RD: when both temperature and humidity are at low levels, the number of outpatient visits for RD is higher. When the relative humidity is ≤50% and the temperature is ≤11°C, total RD outpatient visits increase by 4.502% for every 1°C drop in temperature; that is, a dry environment with low temperature has the most significant impact on RD.

Forecast of Outpatient Visits to a Tertiary Eyecare Network in India Using the EyeSmart Electronic Medical Record System.

India is home to 1.3 billion people. The geography and the magnitude of the population present unique challenges in the delivery of healthcare services. The implementation of electronic health records and tools for conducting predictive modeling enables opportunities to explore time series data like patient inflow to the hospital. This study aims to analyze expected outpatient visits to the tertiary eyecare network in India using datasets from a domestically developed electronic medical record system (eyeSmart™) implemented across a large multitier ophthalmology network in India. Demographic information of 3,384,157 patient visits was obtained from eyeSmart EMR from August 2010 to December 2017 across the L.V. Prasad Eye Institute network. Age, gender, date of visit and time status of the patients were selected for analysis. The datapoints for each parameter from the patient visits were modeled using the seasonal autoregressive integrated moving average (SARIMA) modeling. SARIMA (0,0,1)(0,1,7)7 provided the best fit for predicting total outpatient visits. This study describes the prediction method of forecasting outpatient visits to a large eyecare network in India. The results of our model hold the potential to be used to support the decisions of resource planning in the delivery of eyecare services to patients.

P0183 - Impact of the COVID-19 pandemic on urologic care delivery in the United States

Plain language summaryOutpatient visits and surgical procedures declined and recovered, and the magnitude of both varied by many factors, such as race, insurance type, location, urgency of diagnosis and procedure. The impact of delayed treatment and the differences in decline and recovery should inform approaches for the ongoing treatment of patients both during and post pandemic. Purpose We examined changes in urologic care delivery due to COVID-19 in the US based on patient, practice, and local/regional demographic and pandemic response features. Materials and methods We analyzed real-world data from the American Urological Association Quality (AQUA) Registry collected from electronic health record systems. Data represented 157 outpatient urologic practices and 3,165 providers across 48 US states and territories, including 3,297,721 unique patients, 12,488,831 total outpatient visits, and 2,194,456 procedures. The primary outcome measure was the number of outpatient visits and procedures performed (inpatient or outpatient) per practice per week, measured from January 2019 to February 2021. Results We found large (>50%) declines in outpatient visits from March 2020 to April 2020 across patient demographic groups and states, regardless of timing of state stay-at-home orders. Non-urgent outpatient visits decreased more across various non-urgent procedures (49-59%) than for procedures performed for potentially urgent diagnoses (38-52%); surgical procedures for non-urgent conditions also decreased more (43-79%) than those for potentially urgent conditions (43-53%). African American patients had similar decreases in outpatient visits compared with Asians and Caucasians, but also slower recoveries back to baseline. Medicare-insured patients had the steepest declines (55%) while those on Medicaid and Government insurance had the lowest percentage of recovery to baseline (73, and 69% respectively). Conclusions This study provides real-world evidence on the decline in urologic care across demographic groups and practice settings, and demonstrates a differential impact on the utilization of urologic health services by demographics and procedure type.

Abdominal Pain and Depression, Not Bowel Habits, Predict Health Care Utilization in Patients With Functional Bowel Disorders.

Patients with disorders of gut-brain interaction (DGBIs) are high users of health care. Past studies exploring predictors of utilization have lacked patient-level clinical data. The aim of the current study is to identify demographic, clinical, and psychological predictors of health care utilization in patients with irritable bowel syndrome (IBS), functional constipation (FC), and functional diarrhea (FDr). Consecutive new patients diagnosed with IBS, FC, and FDr (using Rome IV criteria) completed questionnaires assessing health care utilization as well as clinical and psychological symptoms. Health care utilization was assessed using a 13-item measure inquiring about the previous 6 months. Patient-Reported Outcome Measures Information System (PROMIS) was used to assess severity of abdominal pain, constipation, diarrhea, anxiety, depression, and sleep disturbance. Of the 507 patients diagnosed with IBS, FC, or FDr, 434 completed the health care utilization questionnaire (mean age of 44 years, 79.5% female, and 73.5% IBS). In the final multivariable models, more severe abdominal pain and higher depression scores were significantly associated with increased utilization of (i) total outpatient visits, (ii) outpatient visits for gastrointestinal (GI) symptoms, and (iii) number of medications for GI symptoms. More severe abdominal pain was also significantly predictive of GI-related emergency department visits. Altered bowel habits were not consistent predictors of health care utilization. Severity of abdominal pain and depressive symptoms, but not bowel habits, is a primary driver of increased care-seeking behavior in patients with IBS, FC, and FDr.

Possible Effects on VA Outpatient Care of Expanding Medicaid: Implications of Having Access to Overlapping Publicly Funded Health Care Services.

Because veterans who use Veterans Health Administration (VA) health care retain VA eligibility while enrolling in Medicaid, increasing Medicaid eligibility may create improved health system access but also create unique challenges for the quality and coordination of health care for veterans. We analyze how pre-Affordable Care Act (ACA) state Medicaid expansions influence VA and Medicaid-funded outpatient care utilization. This study uses Difference-in-difference analysis to evaluate association between pre-ACA 2001 Medicaid expansions and VA utilization in a natural experiment. Veterans aged 18-64 years living in a study state during the study period were the participants. Dependent variables included participants' proportion of outpatient care received at the VA, whether a participant recorded care with both Medicaid and the VA, and total outpatient utilization. We analyzed changes between two states that expanded Medicaid in 2001 against three similar states that did not from 1999 to 2006. We adjusted for age, non-White race, gender, disease burden, and distance to VA facilities. This study was approved by the Baylor College of Medicine Institutional Review Board (IRB), protocol number H-40441. In total, 346,364 VA-enrolled veterans lived in the five study states during the time of our study, 70,987 of whom were enrolled in Medicaid for at least 1 month. For low-income veterans, Medicaid expansion was associated with a 2.88 percentage-point decline in the VA proportion of outpatient services (99% CI -3.26 to -2.49), and a 2.07-point increase (1.80 to 2.35) in the percentage of patients using both VA and Medicaid services. Results also showed small increases in total (VA plus Medicaid) annual per-capita outpatient visits among low-income veterans. We estimate that this corresponds to an annual reduction of 80,338 VA visits across study states (66,155-94,521). This study shows usage shifts when Medicaid expansion allows veterans to gain access to non-VA care. It highlights increased potential for care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional public health insurance options, as well as programs like CHOICE and the MISSION Act that increase veteran choices of traditional VA and community care providers.

61 Real-time Burn Outpatient Virtual Visits in the Home During the Era of COVID-19

IntroductionThe majority of burn injured patients travel long distances to receive burn care from regional burn centers, creating a burden on families and impairing outcomes. Recent federal policies in response to the COVID-19 pandemic have relaxed some of the barriers to virtual visits in the non-health care setting. We sought to review the experience of a comprehensive burn program in managing burn patients with a virtual platform.MethodsA clinical quality database was maintained to evaluate virtual videoconference and in-person clinic visits for a comprehensive adult and pediatric burn program during the COVID-19 pandemic (March 2020 to August 2020). Virtual visits utilized a telemedicine platform that employs real-time audio and video communication. Demographic, burn severity, and visit quality data were recorded. Zip code data was also collected and then used to calculate the following estimated savings for the patient and their family: total miles, travel hours, driving costs, and wages.ResultsA total of 145 patients were included in this study with 96 (66.2%) male and 49 (33.7%) female. 91 (62.8%) were pediatric patients with a mean age of 6.2 ± 0.5 years and 54 (37.2%) were adult patients with a mean age of 40.4 ± 2.5 years. There were 320 total burn outpatient follow-up visits with 199 pediatric visits (40 virtual and 159 in-person) and 121 adult visits (24 virtual and 97 in-person). The majority of patients (73.1%) were treated as in-person visits while 6.9% had purely virtual visits, and 20.0% of patients had both virtual and in-person visits. The following savings were associated with virtual visits: 8562.6 total miles (average 133.8 ± 42.4), $6789.29 total driving cost (average $106.08 ± 33.61), 161.5 total travel hours (average 2.5 ± 0.7), and $4758.42 total wages lost to travel (average $74.35 ± 21.43). Technical issues were only reported in 14% of total visits (2.5% of pediatric virtual visits and 33.3% of adult virtual visits).ConclusionsOutpatient virtual visits for burn care are a new frontier, driven by improvements in technology and reduced barriers to reimbursement. This study demonstrates that virtual visits are associated with major financial and temporal benefits for patients and their families. Technical issues remain an important barrier, particularly in the adult population. A clear understanding of this and other barriers may improve implementation of this new healthcare delivery paradigm.

Variation In Telemedicine Use And Outpatient Care During The COVID-19 Pandemic In The United States.

Coronavirus disease 2019 (COVID-19) spurred a rapid rise in telemedicine, but it is unclear how use has varied by clinical and patient factors during the pandemic. We examined the variation in total outpatient visits and telemedicine use across patient demographics, specialties, and conditions in a database of 16.7million commercially insured and Medicare Advantage enrollees from January to June 2020. During the pandemic, 30.1percent of all visits were provided via telemedicine, and the weekly number of visits increased twenty-three-fold compared with the prepandemic period. Telemedicine use was lower in communities with higher rates of poverty (31.9percent versus 27.9percent for the lowest and highest quartiles of poverty rate, respectively). Across specialties, the use of any telemedicine during the pandemic ranged from 68percent of endocrinologists to 9percent of ophthalmologists. Across common conditions, the percentage of visits provided during the pandemic via telemedicine ranged from 53percent for depression to 3percent for glaucoma. Higher rates of telemedicine use for common conditions were associated with smaller decreases in total weekly visits during the pandemic.

Healthcare Utilization Among Children and Adolescents with Sickle Cell Disease during the COVID-19 Pandemic

BackgroundEarly experience with the COVID-19 pandemic showed disproportionately high morbidity and mortality among individuals with certain chronic medical conditions. Individuals with sickle cell disease (SCD) are at high risk for pulmonary and other complications including acute chest syndrome (ACS) and have high rates of hospitalization from other viral respiratory infections, raising concern that COVID-19 would be associated with higher morbidity, mortality and health care utilization among those with SCD. Public health interventions such as social distancing, avoidance of large group activities, and widespread use of masks have been shown to reduce the transmission of COVID-19 in the general population but have been inconsistently implemented. In Georgia, COVID-19 restrictions, including school closures, were implemented in mid-March, and on-site school instruction was replaced by virtual instruction for the remainder of the school year. At our institution, most routine, non-urgent outpatient clinic visits were cancelled or postponed from mid-March through May in order to minimize COVID-19 exposure risk. Efforts to initiate the use of telemedicine as an alternative to in-person office visits were rapidly instituted. We hypothesized that adherence to public health restrictions, especially sheltering in place, would be high among patients and families with SCD, and sought to measure the impact of COVID pandemic on healthcare utilization in children and adolescents with SCD in the Atlanta area.MethodsThe SCD Program at Children's Healthcare of Atlanta (CHOA) provides comprehensive outpatient, emergency and inpatient services at 3 locations in metropolitan Atlanta. CHOA's Sickle Cell Clinical Database (SCCD) contains prospectively collected demographic, diagnostic, treatment and other clinical information on all patients with SCD beginning in 2010, including all outpatient clinic, emergency department (ED) and inpatient hospital utilization. To assess the impact of COVID-19 on healthcare utilization, we tracked clinic, ED and inpatient utilization for the 4-month period (March through June) 2020 compared with the same 4-month period in 2018 and 2019.ResultsThe figure shows utilization patterns for each four-month period from 2018-2020. As expected, face to face outpatient clinic visits fell dramatically from February to April 2020 (-25% in March, -64% in April) and then returned to pre-COVID levels by June. The addition of telemedicine visits raised total outpatient visits in June 2020 to above pre-COVID levels. Total utilization during the 4-month period in 2020 were compared to the mean for the same periods in 2018 and 2019. Face to face clinic visits decreased from 2971.5 to 2023 (-32%), ED visits from 1,217 to 687 (-44%), and total inpatient admissions from 699 to 410 (-41%). Admissions with a primary discharge diagnosis of pain decreased from a mean of 407 in 2018-2019 to 173 (-57%), fever/infection from 67.5 to 40 (-41%), and ACS from 101 to 75 (-26%). Patients with chronic pain and/or history of high utilization (>5 admissions in a given year) showed decreases in utilization similar to all other patients.SummaryThese data describe the significant changes in utilization among pediatric patients with SCD during the COVID-19 pandemic. Face to face outpatient clinic visits decreased during March and April but returned to pre-COVID levels in June. Unexpectedly, ED and inpatient hospital utilization for acute illness decreased dramatically through April and remained low through June. In March there was a significant decrease in the clinic setting due to a large number of cancelled or rescheduled outpatient visits, despite many being rescheduled as telemedicine visits. However, the largest unexpected decrease was seen in emergency department visits and hospitalizations for acute events, specifically fever and pain events. It is also important to note the decreased utilization of patients with chronic pain who are typically high utilizers. During clinic encounters, families mentioned that less stress from school, reduced respiratory infections, and better medication adherence with parents at home, were possible contributors to reduced sickle cell symptoms while sheltering in place. These observations will guide the development of a patient survey with the goal of obtaining qualitative data to explain the reasons for decreased utilization during the pandemic.FigureDisclosuresLane:FORMA Therapeutics: Membership on an entity's Board of Directors or advisory committees; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees.

Who Benefits from the Fixed Copayment of Medical and Pharmaceutical Expenditure among the Korean Elderly?

The Korean National Health Insurance system imposes a 30% coinsurance for outpatient medical care and prescription drugs; however, at the age of 65, the coinsurance model changes to a copayment model that offers lower fees for the elderly. Thus, this study aimed to investigate the influence of the copayment model for outpatient visits and prescription drugs on healthcare utilization among the Korean elderly. We compared total outpatient visits, total prescriptions, and out-of-pocket expenses between a case group with copayment reduction (65 years or older) and a control group without any reduction (64 years or younger). We obtained secondary data collected from seven waves of the Korea Health Panel Survey (2010–2016). Outpatient visits increased exclusively in the case group among those with lower income. After adjusting for covariates, the results of the difference-in-differences analysis showed that, compared to the control group, there was a significant increase in outpatient visits among individuals with lower income in the case group. Our study shows that cost sharing changes affect Korean patients with different income levels in different ways.

Effects of the COVID-19 Pandemic on Outpatient Providers in the United States.

During the COVID-19 pandemic, there is concern that social distancing, fear of contagion, quarantining of providers, cancellation of elective procedures, media coverage about the pandemic, and other factors drastically reduced physician visits, putting severe financial strain on outpatient providers, and having unknown ramifications for health outcomes. We estimate the effect of the pandemic on utilization of outpatient services. Using 2010-2020 data from a national dataset, the Outpatient Influenza-like Illness Surveillance Network, we estimate the difference in outpatient care utilization during the time period of the COVID-19 pandemic versus the same weeks in prior years. Our findings indicate that the pandemic started to reduce visits during the week of March 15-21. The effect on visits grew until reaching a peak during the week of April 5-11, 2020, when the pandemic reduced the total number of outpatient visits per provider by 70% relative to the same week in prior years. We find negative effects of the pandemic on visits for non-flu symptoms as well as on visits for flu symptoms, but the magnitudes of these latter effects tended to be larger in magnitude. The pandemic's impact declined over time, and by the week of June 28 to July 4, 2020, there was no longer any difference in total visits per provider relative to the same week in prior years. Despite the resurgence of COVID-19 in June and July, we still find no effects on total visits when our data end in July 26 to August 1, 2020. Our findings show that one by-product of the COVID-19 pandemic in the United States is a large decline in the use of outpatient care which peaked around the week of April 5-11. Total outpatient visits rebounded completely and remain stable as of July 26 to August 1, 2020.

Physician Home Visit Patterns and Hospital Use Among Older Adults with Functional Impairments.

Home-based primary care has been associated with reductions in hospital use among homebound older adults, but population-based studies on the general home visit patterns of primary care physicians are lacking. We examined the association between the provision of home visits by primary care physicians and subsequent use of hospital-based care among their older adult patients with extensive functional impairments. Population-based retrospective cohort study. The setting was Ontario, Canada, from October 2014 to September 2016. Older adults (aged ≥65 years) with extensive functional impairments receiving publicly funded home care. We measured the provision of home visits by a patient's most responsible primary care physician during the year before a comprehensive home care assessment. Physician home visit patterns were measured as the proportion of the total outpatient visits in a year that were home visits, categorized with quartiles. Multivariable, multilevel negative binomial regression models examined the associations between physician-level home visit provision and patient emergency department visits and hospital admissions over the 6 months following the home care assessment. There were 49,613 patients in the cohort who were linked to 8,096 unique primary care physicians. A total of 69.1% of physicians provided at least one home visit in a year, with the median proportion of home visits to total visits ranging from 0.057% to 3.19% across quartiles. Patients whose physicians were in the highest home visit provision quartile had lower rates of emergency department visits (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI] = 0.90-0.96) and hospital admissions (IRR = 0.89; 95% CI = 0.85-0.93) compared with patients whose physician did not do home visits. Home care patients with extensive functional impairments whose physicians provided higher levels of home visits had fewer emergency department visits and hospital admissions. Expanding home visits by primary care physicians could reduce hospital use by older adults living with functional impairments in the community.

Comparison of FreeHand® robot-assisted with human-assisted laparoscopic fundoplication

Objective To compare the safety, operative time and feasibilty of FreeHand® robot (FreeHand Ltd, Guildford, United Kingdom) with manual camera control approach for Laparoscopic Fundoplication. Material and methods A case control study was performed for patients undergoing laparoscopic fundoplication. Primary outcome was operative time; secondary outcomes included length of stay, post-operative morbidity, symptoms at first follow-up and total post-operative out-patient visits. Results Forty-four patients underwent laparoscopic fundoplication between January 2014 and June 2016. Twenty-six (59%) underwent conventional human-assisted fundoplication while 18 (41%) had FreeHand® robot assisted procedures. Mean operative time for conventional laparoscopic fundoplication was 165 min compared with 129 min in the robot-assisted group, saving 36 min (p < .001). The median length of stay was 1.5 days in the robot-assisted as compared to two days in the conventional group. Sixteen percent of robot-assisted as opposed to 30% of conventional group patients experienced complications. There was no 30-day mortality. Two patients required more than one post-operative clinic visit in robot-assisted against six in conventional group. Conclusion Robot-assisted fundoplication is safe, feasible and reduces operative time. Furthermore, this negates need of assistant. Mean operative time for robot-assisted fundoplication was 36 min less than for conventional fundoplication. Advantages also include fewer adverse events, shorter length of stay and less post-operative clinic visits.

Association of air pollution with outpatient visits for respiratory diseases of children in an ex-heavily polluted Northwestern city, China

BackgroundA great number of studies have confirmed that children are a particularly vulnerable population to air pollution.MethodsIn the present study, 332,337 outpatient visits of 15 hospitals for respiratory diseases among children (0–13 years), as well as the simultaneous meteorological and air pollution data, were obtained from 2014 to 2016 in Lanzhou, China. The generalized additive model was used to examine the effects of air pollutants on children’s respiratory outpatient visits, including the stratified analysis of age, gender and season.ResultsWe found that PM2.5, NO2 and SO2 were significantly associated with the increased total respiratory outpatient visits. The increments of total respiratory outpatient visits were the highest in lag 05 for NO2 and SO2, a 10 μg/m3 increase in NO2 and SO2 was associated with a 2.50% (95% CI: 1.54, 3.48%) and 3.50% (95% CI: 1.51, 5.53%) increase in total respiratory outpatient visits, respectively. Those associations remained stable in two-pollutant models. Through stratification analysis, all air pollutants other than PM10 were significantly positive associated with the outpatients of bronchitis and upper respiratory tract infection. Besides, both NO2 and SO2 were positively related to the pneumonia outpatient visits. PM2.5 and SO2 were significantly related to the outpatient visits of other respiratory diseases, while only NO2 was positively associated with the asthma outpatients. We found these associations were stronger in girls than in boys, particularly in younger (0–3 years) children. Interestingly, season stratification analysis indicated that these associations were stronger in the cold season than in the transition or the hot season for PM10, PM2.5 and SO2.ConclusionsOur results indicate that the air pollution exposure may account for the increased risk of outpatient visits for respiratory diseases among children in Lanzhou, particularly for younger children and in the cold season.

Health Care Resource Utilization of Late Premature Versus Term Infants With Bronchiolitis

It is controversial whether it is cost-beneficial for late preterm infants to receive respiratory syncytial virus prophylaxis. This study compares community and hospital health care resource utilization (HCRU) of late premature infants (33-36 weeks gestational age) with term infants (>36 weeks gestational age) hospitalized with bronchiolitis. This was a retrospective, population-based, observational study spanning a 9-year period (2004-2012). HCRU data were obtained from the Health Maintenance Organization "Clalit" and included duration of hospitalization, physician visits, laboratory tests, and treatments. Compared with term infants, late preterm infants had significantly longer duration of hospitalization and higher admission rates to pediatric intensive care unit. They also had higher rates of mean outpatients clinic visits, total outpatient clinic and specialist visits, blood chemistry, and virology testing. HCRU of term infants with bronchiolitis was also substantial, indicating that they also can greatly benefit from respiratory syncytial virus prophylaxis. These findings can guide stakeholders in decisions concerning the prevention of bronchiolitis and will be useful in performing further cost-benefit analysis.

Factors Associated With Urgent Care Reliance and Outpatient Health Care Use Among Children Enrolled in Medicaid

Urgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use. To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use. A retrospective cohort study used deidentified data on 4 133 238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or more UC, emergency department (ED), primary care provider (PCP; physician, advanced practice nurse, or physician assistant; well-child care [WCC] or non-WCC), or specialist outpatient visit during the 2017 calendar year. Statistical analysis was conducted from November 11 to 26, 2019. Urgent care, ED, PCP (WCC and non-WCC), and specialist visits based on coded location of services. Urgent care reliance, calculated by the number of UC visits divided by the sum of total outpatient (UC, ED, PCP, and specialist) visits. High UC reliance was defined as UC visits totaling more than 33% of all outpatient visits. Of 4 133 238 children in the study, 2 090 278 (50.6%) were male, with a median age of 9 years (interquartile range, 4-13 years). A total of 223 239 children (5.4%) had high UC reliance. Children 6 to 12 years of age were more likely to have high UC reliance compared with children 13 to 18 years of age (adjusted odds ratio, 1.07; 95% CI, 1.06-1.09). Compared with white children, black children (adjusted odds ratio, 0.81; 95% CI, 0.81-0.82) and Hispanic children (adjusted odds ratio, 0.61; 95% CI, 0.60-0.61) were less likely to have high UC reliance. Adjusted for age, sex, race/ethnicity, and presence of chronic or complex conditions, children with high UC reliance had significantly fewer PCP encounters (WCC: adjusted rate ratio, 0.60; 95% CI, 0.60-0.61; and non-WCC: adjusted rate ratio, 0.41; 95% CI, 0.41-0.41), specialist encounters (adjusted rate ratio, 0.31; 95% CI, 0.31-0.31), and ED encounters (adjusted rate ratio, 0.68; 95% CI, 0.67-0.68) than children with low UC reliance. High UC reliance occurred more often in healthy, nonminority, school-aged children and was associated with lower health care use across other outpatient settings. There may be an opportunity in certain populations to ensure that UC reliance does not disrupt the medical home model.

Critical Predictors for the Early Detection of Conversion From Unipolar Major Depressive Disorder to Bipolar Disorder: Nationwide Population-Based Retrospective Cohort Study.

BackgroundUnipolar major depressive disorder (MDD) and bipolar disorder are two major mood disorders. The two disorders have different treatment strategies and prognoses. However, bipolar disorder may begin with depression and could be diagnosed as MDD in the initial stage, which may later contribute to treatment failure. Previous studies indicated that a high proportion of patients diagnosed with MDD will develop bipolar disorder over time. This kind of hidden bipolar disorder may contribute to the treatment resistance observed in patients with MDD.ObjectiveIn this population-based study, our aim was to investigate the rate and risk factors of a diagnostic change from unipolar MDD to bipolar disorder during a 10-year follow-up. Furthermore, a risk stratification model was developed for MDD-to-bipolar disorder conversion.MethodsWe conducted a retrospective cohort study involving patients who were newly diagnosed with MDD between January 1, 2000, and December 31, 2004, by using the Taiwan National Health Insurance Research Database. All patients with depression were observed until (1) diagnosis of bipolar disorder by a psychiatrist, (2) death, or (3) December 31, 2013. All patients with depression were divided into the following two groups, according to whether bipolar disorder was diagnosed during the follow-up period: converted group and nonconverted group. Six groups of variables within the first 6 months of enrollment, including personal characteristics, physical comorbidities, psychiatric comorbidities, health care usage behaviors, disorder severity, and psychotropic use, were extracted and were included in a classification and regression tree (CART) analysis to generate a risk stratification model for MDD-to-bipolar disorder conversion.ResultsOur study enrolled 2820 patients with MDD. During the follow-up period, 536 patients were diagnosed with bipolar disorder (conversion rate=19.0%). The CART method identified five variables (kinds of antipsychotics used within the first 6 months of enrollment, kinds of antidepressants used within the first 6 months of enrollment, total psychiatric outpatient visits, kinds of benzodiazepines used within one visit, and use of mood stabilizers) as significant predictors of the risk of bipolar disorder conversion. This risk CART was able to stratify patients into high-, medium-, and low-risk groups with regard to bipolar disorder conversion. In the high-risk group, 61.5%-100% of patients with depression eventually developed bipolar disorder. On the other hand, in the low-risk group, only 6.4%-14.3% of patients with depression developed bipolar disorder.ConclusionsThe CART method identified five variables as significant predictors of bipolar disorder conversion. In a simple two- to four-step process, these variables permit the identification of patients with low, intermediate, or high risk of bipolar disorder conversion. The developed model can be applied to routine clinical practice for the early diagnosis of bipolar disorder.

Impact of Gastrointestinal Surgical Site Wound Complications on Long-term Healthcare Utilization

ImportanceWound complication following gastrointestinal surgery substantially impacts the quality and costs of surgical care. The impact of wound complication on subsequent long-term healthcare utilization has not been fully studied. ObjectiveWe assessed the impact of surgical wound complication on inpatient and outpatient healthcare utilization in the 2 years after gastrointestinal (GI) surgery. DesignAn observational retrospective cohort study was conducted on Veterans Affairs health system patients who underwent an inpatient GI surgical procedure, were assessed by the Veterans Affairs Surgical Quality Improvement Program (VASQIP), and were discharged alive from Veterans Affairs (VA) hospitals between October 1, 2007 and September 30, 2014. SettingPopulation-based ParticipantsA total of 64,351 patients underwent a GI surgical procedure in the VA system between 2007 and 2014. The cohort was 93.5% male, with a median age of 63.0 years (interquartile range (IQR) 57.0–70.0). A total of 7880 patients (12.2%) had at least one reported wound complication, 5460 of which had their postoperative wound complication classified by a VASQIP nurse. ExposureVASQIP-assessed or ICD-9-coded wound complication in the 30 days after surgery Main Outcome MeasurementsInpatient visits, total inpatient days, outpatient visits, and emergency department visits, and operative interventions up to 2 years after discharge from index admission ResultsPatients with a postoperative wound complication had greater inpatient healthcare utilization compared with no-wound complication for up to 2 years after surgery: inpatient admissions (mean number 3.5 vs. 2.8; P < .001), inpatient bed days (mean 41.0 vs. 25.0; P < .001). Patients with a postoperative wound complication also had greater 2-year outpatient utilization than the no-wound complication cohort: outpatient visits (mean number 92.7 vs. 75.9; P < .001) and emergency department visits (mean 3.5 vs. 2.7; P < .001). The same relationship held for wound-related parameters; inpatient admissions (2.2 vs. 0.4; P < .001); inpatient bed days (21.4 vs. 3.7; P < .001); and outpatient visits (56.2 vs. 9.7; P < .001). A greater proportion of patients in the wound complication cohort had an operative intervention for all time intervals examined (P < .001). ConclusionsSurgical wound complications impact healthcare utilization patterns for up to 2 years after the index procedure including hospital readmissions and operative interventions; efforts to reduce postoperative wound complications will have substantial effects on patient outcomes and healthcare expenditures well beyond the 30-day postoperative period.

Seeking Patient-and Family-Centered Care: The Experiences of Families of Children with an Autism Spectrum Disorder

Children with an autism spectrum disorder (ASD) have a higher annual mean number of total clinic, pediatric, and psychiatric outpatient visits, and inpatient and outpatient hospitalizations when compared to children without ASD. Families of individuals with ASD observe and experience specific barriers to medical care. Using a mixedmethods approach and interpretive phenomenological analysis (IPA), the perspectives of 40 families were gathered through a survey to gain a better understanding of positive and negative experiences, and the implications for healthcare providers and medical settings. Among the themes identified, families shared the need for healthcare providers to be more knowledgeable and trained about the heterogeneity of ASD, to presume competence and to view families as allies in facilitating medical encounters. As a result of these improvements, families also hope that healthcare providers develop greater compassion for families of children with ASD.

Job training and organizational performance: Analyses from medical institutions in China

The benefit of training on economic outcomes has been well-documented in previous literature, as training is generally recognized as one of the important approaches in human capital investment. However, the return of employee training on organizational level performance is not verified sufficiently, especially in the healthcare field. By taking advantage of a dataset with the information on all medical institutions in Sichuan, China over 2012–2016, this paper investigates the effects of employee training on medical institution’s performance through the Propensity Score Matching (PSM) method and the Event Study approach. The results show that training benefits medical institution performance in some indicators, such as total visits, outpatient visits, non-medical-insurance, and local competitiveness. These effects, however, vary across different types of medical institutions. Grassroot medical institutions in the county area that serve as a health gatekeeper (known as primary health care institution, PHCIs) gain most in hospital visits after training. In addition, training results in a 16.5% increase in the average performance wage for county-PHCIs, and a 52.8% increase in the employees’ performance wage for higher-level general hospitals in cities. In general, by participating in training, PHCIs in county region gain more in the overall revenue through the non-medical-insurance income.

P036 Socioeconomic Disparities in IBD: Outcomes in Emergency Department Utilization and Outpatient Follow-Up

BACKGROUND: The association of socioeconomic status, emergency department (ED) utilization, and access to outpatient gastroenterology care in inflammatory bowel disease (IBD) remains underexplored. We sought to identify associations between overall socioeconomic deprivation and these outcomes in IBD patients. METHODS: Our historical cohort included 743 unique IBD patients with a total of 6,036 all-cause ED visits during a 51-month period (January 1, 2015 to April 1, 2019). Detailed demographic variables were recorded for all subjects. Zip codes were used to approximate the level of socioeconomic deprivation via the Area Deprivation Index (ADI), a comprehensive score developed at the University of Wisconsin based on a composite score including 17 different factors related to income, education, employment, and housing quality (1). ADI scores of these IBD patients were divided into quartiles (quartile 4 = most deprived) and then compared with outcomes, including average number of ED visits, average hours spent in ED per visit, acuity level of ED visits (by Emergency Severity Index levels 1–5, with level 1 = highest acuity), admission rates, total outpatient GI visits and IBD-specialist visits, percent attending any outpatient GI visit or IBD specialist visit, and initiation of any outpatient steroid-sparing therapies. Univariate comparisons were performed using analysis of variance (ANOVA) for continuous variables and chi-square tests for categorical variables. Statistical significance was set at P < 0.05. RESULTS: 743 IBD patients (60% female, age 48 ± 18 yrs, 446 with Crohn's disease (CD), 297 with ulcerative colitis (UC)) were evaluated. Basic demographics were similar overall, with significant differences noted in race (P < 0.001) and insurance coverage (P < 0.001). Increased ED visits were noted with increased ADI in IBD patients overall (P = 0.003) as well as in the subgroup with CD (P = 0.040). Patients with increased ADI averaged fewer hours in the ED (P = 0.043), although they presented with significantly higher acuity (P = 0.007). There was a trend towards decreased GI clinic visits with increased ADI, but this did not reach statistical significance (p = 0.055). There was a significant difference between ADI quartiles in terms of those who successfully attended at least one GI clinic follow-up visit for all IBD patients (P = 0.007) and specifically for those with CD (P = 0.012). Patients with increased ADI attended fewer IBD-specific clinic follow up (P = 0.044). Significant differences regarding access to outpatient steroid-sparing therapy were seen across ADI quartiles (P = 0.044). CONCLUSION(S): Our study demonstrates increased ED utilization and decreased access to outpatient gastroenterology and IBD specialty care in IBD patients with lower socioeconomic status. Limitations include minor differences in baseline demographics including race and insurance coverage, although confounding was minimized by utilization of a comprehensive assessment of socioeconomic status through the ADI model. Our findings highlight the need for better access to outpatient IBD care in more economically deprived areas, and community health intervention programs to improve awareness of specialty care.