Triage Visits Research Articles

Evaluating the Implementation and Clinical Effectiveness of an Innovative Digital First Care Model for Behavioral Health Using the RE-AIM Framework: Quantitative Evaluation.

In the United States, innovation is needed to address the increasing need for mental health care services and widen the patient-to-provider ratio. Despite the benefits of digital mental health interventions (DMHIs), they have not been effective in addressing patients' behavioral health challenges as stand-alone treatments. This study evaluates the implementation and effectiveness of precision behavioral health (PBH), a digital-first behavioral health care model embedded within routine primary care that refers patients to an ecosystem of evidence-based DMHIs with strategically placed human support. Patient demographic information, triage visit outcomes, multidimensional patient-reported outcome measure, enrollment, and engagement with the DMHIs were analyzed using data from the electronic health record and vendor-reported data files. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework was used to evaluate the implementation and clinical effectiveness outcomes of PBH. PBH had a 47.58% reach rate, defined as patients accepting the PBH referral from their behavioral health integrated clinician. PBH patients had high DMHI registration rates (79.62%), high activation rates (76.54%), and high retention rates at 15 days (57.69%) and 30 days (44.58%) compared to literature benchmarks. In total, 74.01% (n=168) of patients showed clinical improvement, 22.47% (n=51) showed no clinical change, and 3.52% (n=8) showed clinical deterioration in symptoms. PBH had high adoption rates, with behavioral health integrated clinicians referring on average 4.35 (SD 0.46) patients to PBH per month and 90%-100% of clinicians (n=12) consistently referring at least 1 patient to PBH each month. A third (32%, n=1114) of patients were offered PBH as a treatment option during their triage visit. PBH as a care model with evidence-based DMHIs, human support for patients, and integration within routine settings offers a credible service to support patients with mild to moderate mental health challenges. This type of model has the potential to address real-life access to care problems faced by health care settings.

Antihypertensive therapy and unplanned maternal postpartum healthcare utilization in patients with mild chronic hypertension

ObjectiveTo test whether treatment of mild chronic hypertension (CHTN) in pregnancy is associated with lower rates of unplanned maternal healthcare utilization postpartum. MethodsThis was a secondary analysis of the CHTN and pregnancy study, a prospective, open-label, pragmatic, multicenter, randomized treatment trial of pregnant people with mild CHTN. All patients with a postpartum follow-up assessment were included. The primary outcome was unplanned healthcare utilization, defined as unplanned postpartum clinic visits, Emergency Department (ED) or triage visits, or unplanned hospital admissions within 6 weeks postpartum. Differences in outcomes were compared between study groups (Active Group: blood pressure goal of<140/90 mm Hg, and Control Group: blood pressure goal of <160/105 mm Hg), and factors associated with outcomes were examined using logistic regression. ResultsA total of 2293 patients were included with 1157 (50.5%) in the active group and 1136 (49.5%) in the control group. Rates of unplanned maternal postpartum healthcare utilization did not differ between treatment and control groups, (20.2% vs 23.3%, P=.07, aOR 0.84, 95% CI 0.69–1.03). However, ED or triage/maternity evaluation unit visits were significantly lower in the Active group (10.2% vs 13.2%, P=.03, aOR 0.76, 95% 0.58–0.99). Higher BMI at enrollment and cesarean delivery were associated with higher odds of unplanned postpartum healthcare utilization. ConclusionWhile treatment of mild CHTN during pregnancy and postpartum was not significantly associated with overall unplanned healthcare resource utilization, it was associated with lower rates of postpartum ED and triage visits.

Factors associated with hospital revisitation within 7 days among patients discharged at triage: a case-control study.

Existing data are limited for determining the medical conditions best suited for an emergency department (ED) redirection strategy in a heterogeneous, nonurgent patient population. The aim was to establish factors associated with hospital revisits within 7 days among patients discharged or redirected by a triage team. An observational single-center case-control study was conducted at the Tampere University Hospital ED for the full calendar year of 2019. The cases comprised unplanned hospital revisits within 7 days of being discharged or redirected by triage, while the controls were discharged or redirected but did not revisit. The primary outcome was an unplanned hospital revisit within 7 days. A subgroup analysis was conducted for revisits leading to hospitalization. Basic demographics, comorbidities before triage, and triage visit characteristics were considered as predictive factors for the revisit. A backward stepwise conditional logistic regression analysis was performed. During the calendar year of 2019, there were a total of 92 406 ED visits. Of these, 7216 (7.8%) visits were discharged or redirected by triage, and 6.5% (n = 467) of all these patients revisited. Of the revisiting patients, 25% (n = 117) were hospitalized. In multivariable analysis, higher age was associated with both revisitation [odds ratio (OR): 1.01, 95% confidence interval (CI): 1.00-1.02] and hospitalization (OR: 1.02, 95% CI: 1.00-1.04). Furthermore, using other visits as a reference, abdominal pain was associated with revisitation and hospitalization (OR: 3.70, 95% CI: 2.24-6.11 and OR: 5.28, 95% CI: 2.08-13.4, respectively). Higher age and abdominal pain were associated with hospital revisitation and hospitalization within 7 days among patients directly discharged or redirected by the triage team. Regardless of the triage system in use, there might be patient groups that should be evaluated more cautiously if a triage-based discharge or redirection strategy is to be considered.

SFlt1/PlGF among patients with suspected preeclampsia when considering hypertensive status

BACKGROUNDIn high-resource settings, biomarkers of angiogenic balance, such as the soluble fms-like tyrosine kinase-1 (sFlt1)/placental growth factor (PlGF) ratio, have been studied extensively to aid in evaluation of patients with suspected preeclampsia (PE), and have been incorporated into the 2021 International Society for the Study of Hypertension in Pregnancy definition of PE. The utility in under-resourced settings has not been as well characterized. OBJECTIVEThis analysis sought to identify the role of the sFlt1/PlGF ratio in the evaluation of patients with or without hypertension who are suspected of having PE without other diagnostic information. STUDY DESIGNThis is a secondary analysis of a prior prospective study of patients who were presented with suspected PE at ≥20+0 weeks’ gestation at a single academic tertiary care center. Patients were recruited in the parent study from July 2009 to June 2012. In the original study, clinicians were masked to biomarker results, and patients were followed by chart review. In this analysis, the performance of the sFlt1/PlGF ratio (≤38, >38, or >85) was assessed alone in identifying both hypertensive and non-hypertensive patients at risk of evolving into PE with severe features (PE-SF; American College of Obstetricians and Gynecologists’ definition) within two weeks of the triage visit (PE-SF2). Hypertension was defined as a blood pressure (BP)≥140/90 mmHg. RESULTSThere were 1043 patients included in the analysis; of whom, 579 (55.5%) and 464 (44.5%) presented with or without hypertension, respectively. In triage, 332 (75.4%) of hypertensive patients presented due to BP concerns, and the remainder were evaluated due to other features (new-onset headache, proteinuria, or edema). On triage evaluation, 66.8% of all patients had a normal sFlt1/PlGF ratio ≤38, and 17.0% had an elevated ratio >85. Among hypertensive patients, a sFlt1/PlGF ratio ≤38 was a good rule-out test for PE-SF2 (negative likelihood ratio [LR-] of 0.15), and a ratio >85 was a good rule-in test (positive likelihood ratio [LR+] of 5.75). Among normotensive patients, sFlt1/PlGF was useful as a rule-in test for ratio >38 (LR+ 5.13) and >85 (LR+ 12.80). Stratified by gestational age, sFlt1/PlGF continued to be a good rule in and good rule out test at <35 weeks among those with hypertension but did not have good test performance ≥35 weeks. sFlt1/PlGF had a good test performance as a rule in test for >85 regardless of gestational age. In triage, 4.3% (30/693) of patients with sFlt1/PlGF ratio <38 had concurrent laboratory evidence of PE, compared with 15.9% (28/176) patients with ratio >85. CONCLUSIONThese findings support the potential for the use of sFlt1/PlGF and BP measurement alone in resource-limited settings where other laboratory tests or clinical expertise are unavailable for risk stratification. Performance of the biomarker varied by the presence of hypertension and gestational age.

Feasibility and acceptability of an HPV self-testing strategy: lessons from a research context to assess for ability to implement into primary care at a national level in Botswana.

The WHO strategy for cervical cancer elimination strives to achieve 70% coverage with high-performance cervical screening. While few low- and middle-income countries have achieved this, high-risk human papillomavirus (hrHPV) self-testing creates the possibility to rapidly upscale access to high-performance cervical screening across resource settings. However, effective hrHPV screening requires linkage to follow-up, which has been variable in prior studies. This study developed and tested an implementation strategy aimed at improving screening and linkage to follow-up care in South East District in Botswana. This study performed primary hrHPV self-testing; those with positive results were referred for a triage visit. Withdrawals for any reason, loss-to follow-up between hrHPV test and triage visit, and number of call attempts to give hrHPV results were also documented. Acceptability of the program to patients was measured as the proportion of patients who completed a triage visit when indicated, meeting the a priori threshold of 80%. Feasibility was defined as the proportion of participants receiving the results and attending follow-up. To assess the associations between participant characteristics and loss-to-follow-up we used log-binomial regressions to estimate risk ratios and 95% confidence intervals (CI). Enrollment of 3,000 women occurred from February 2021 to August 2022. In total, 10 participants withdrew and an additional 33 were determined ineligible after consent, leaving a final cohort of 2,957 participants who underwent self-swab hrHPV testing. Half (50%) of participants tested positive for hrHPV and nearly all (98%) of participants received their hrHPV results, primarily via telephone. Few calls to participants were required to communicate results: 2,397 (82%) required one call, 386 (13%) required 2 calls, and only 151 (5%) required 3-5 calls. The median time from specimen collection to participant receiving results was 44 days (IQR, 27-65). Of all hrHPV positive participants, 1,328 (90%) attended a triage visit. In a large cohort we had low loss-to-follow-up of 10%, indicating that the strategy is acceptable. Telephonic results reporting was associated with high screening completion, required few calls to participants, and supports the feasibility of hrHPV self-testing in primary care followed by interval triage.

Evaluating Standard of Care and Obstetrical Outcomes in a Reduced Contact Prenatal Care Model in the COVID-19 Pandemic.

We aimed to investigate the impact of reduced contact prenatal care necessitated by the COVID-19 pandemic on meeting standards of care and perinatal outcomes. This was a retrospective case-control study of patients in low-risk obstetrics clinic at a tertiary care county facility serving solely publicly insured patients comparing reduced in-person prenatal care (R) over 12 weeks with a control group (C) receiving traditional prenatal care who delivered prior. Total 90 patients in reduced contact (R) cohort were matched with controls (C). There were similar rates of standard prenatal care metrics between groups. Gestational age (GA) of anatomy ultrasound was later in R (p = 0.017). Triage visits and missed appointments were similar, though total number of visits (in-person and telehealth) was higher in R (p = 0.043). R group had higher GA at delivery (p = 0.001). Composite neonatal morbidity and length of stay were lower in R (p = 0.017, p = 0.048). Maternal and neonatal outcomes did not otherwise differ between groups. Using Kotelchuck Adequacy of Prenatal Care Utilization index, R had higher rates of adequate prenatal care (45.6% R vs. 24.4% C, p = 0.005). Our study demonstrates the non-inferiority of a hybrid, reduced schedule prenatal schedule to traditional prenatal scheduling. In a reduced contact prenatal care model, more patients met criteria for adequate prenatal care, likely due to higher attendance of telehealth visits. These findings raise the question of revising the prenatal care model to mitigate disparities in disadvantaged populations.

A randomized controlled trial comparing the efficacy of nifedipine and enalapril in the postpartum period

Postpartum hypertension is a common medical complication of pregnancy and is associated with increased healthcare use, including unplanned interactions with the medical system and readmission, which can add significant stress to both a newly postpartum patient and the medical care delivery system. We currently do not know what the best antihypertensive treatment for postpartum hypertension is and tend to use antihypertensives commonly used during pregnancy. However, the mechanism of action of angiotensin-converting enzyme inhibitors may be well suited for the pathophysiology of hypertension in the postpartum period and may help to provide better control of hypertension and, in turn, decrease healthcare use. This study aimed to determine if enalapril is superior to nifedipine in preventing prolonged hospitalizations, unplanned medical visits, and/or readmission among women with postpartum hypertension. We performed an open-label, randomized controlled trial(ClinicalTrials.gov registered: NCT04236258)in which patients≥18 years with chronic hypertension, gestational hypertension, or preeclampsia were recruited to receive either 10 mg enalapril daily or 30 mg extended-release nifedipine daily as an initial antihypertensive agent in the period from delivery to 6 weeks postpartum. Recruitment occurred at a tertiary academic hospital from January 2020 to February 2021. Exclusion criteria included being on an antihypertensive when pregnancy started or requiring≥2 daily antihypertensives during pregnancy. The antihypertensive regimen was managed by the participants' obstetrical provider after the initial randomization. The primary outcome was a composite of prolonged hospitalization, unplanned clinic visits, triage visits, and/or readmission. A total of 40 patients in each arm were needed to detect a decrease in the primary outcome rate from 70% to 40% (α=0.05; power 0.80). Analyses were performed based on the intention-to-treat principal, and each arm was oversampled because of the risk for participant dropout. A total of 47 patients were randomized to each arm. Aside from the mode of delivery and twin gestation, the maternal demographics were similar between the 2 groups. The primary outcome occurred in 31 of 47 patients (66%) randomized to the nifedipine group and in 30 of 47 (64%) randomized to the enalapril group (P=.83). There was no significant difference in the primary outcome after controlling for mode of delivery and twin gestation. More patients in the enalapril arm had a second antihypertensive added during their primary hospitalization (16 vs 6) and more patients in the nifedipine arm were still on their antihypertensive at 2 weeks postpartum (42 vs 36). There were no adverse events in either group. Enalapril was not superior to nifedipine when used as an initial antihypertensive in the immediate postpartum period in terms of decreasing healthcare use.

Placental Pathology After Low-Impact Maternal Trauma [ID: 1380074

INTRODUCTION: Placental abruption is the most common cause of fetal death in cases of blunt trauma, and the majority of abruptions occur within 24 hours of the injury. Because of this potential complication, the observation time after trauma remains controversial. Our study aims to demonstrate the incidence of placental abruption and abnormal placental pathology at the time of delivery in women who have experienced low-impact trauma. METHODS: This was a retrospective cohort study of pregnant patients between the years of 2014 and 2020 at MedStar Washington Hospital Center who presented to triage for low-impact trauma identified by “trauma,” “IPV,” “fall,” or “MVA.” MedStar Health Research Institute IRB approved this study. Data from their evaluation during triage visit, mode of delivery, and placental pathology were assessed. Patients were de-identified and analyses included χ2 tests, linear regression, and multinomial logistic regression analyses, as appropriate (α=0.05). RESULTS: Of 184 patients identified, delivery data were available for 144 (79%). The mean time from trauma to delivery was 9 weeks. After delivery, the placental pathology was grossly assessed or sent to pathology, and 76.6% were intact with 7.6% noting an infarct when sent to pathology. Observation time did not predict placental infarction or calcification. The type of trauma did not correlate with mode of delivery (P=.629), prelabor preterm rupture of membranes (P=.746), placental infarct (P=.358), intact placenta (P=.834), or placental calcification (P=.288). CONCLUSION: Although a small percentage of patients who experienced low-impact trauma had infarction identified on placental pathology, no patients experienced clinical or pathologic placental abruption in 24 hours after trauma.

Effect of Maternal Depressive Symptoms on Prenatal Care Utilization and Milestones [ID: 1376259

INTRODUCTION: Depression is a common complication of pregnancy, but research is limited regarding its effect antepartum. This study assessed the relationship between maternal depressive symptoms and prenatal care utilization. METHODS: This retrospective cohort includes pregnant women who completed first- or second-trimester depression screening using the Edinburgh Postnatal Depression Scale (EPDS) between 2020 and 2021. Patient and pregnancy-related characteristics were compared between women who screened positive versus negative for depression. Multivariate logistic regression models were used to estimate odds of completing prenatal care milestones. The IRB approved a consent waiver. RESULTS: Of 718 women who completed the EPDS in early pregnancy, 85 (12%) screened positive for depression. A greater proportion of these women were younger (P=.034), unpartnered (P=.005), publicly insured (P=.013), had a history of substance use (P&lt;.0001) or prior psychiatric diagnosis (P&lt;.0001), and started prenatal care later (P=.002) than those who screened negative. Although there were no significant differences in total routine prenatal care visits (P=.123), the adjusted odds of completing third-trimester milestones including glucose tolerance testing (odds ratio [OR] [95% CI] 0.596 [0.364–0.975]) and group B streptococcus testing (OR [95% CI] 0.559 [0.330–0.947]) were lower among women who screened positive for depression. In addition, higher EPDS scores were positively correlated with number of labor and delivery triage visits (r=0.103, P=.006). CONCLUSION: Women who screen positive for depression during pregnancy are a socially vulnerable group at risk of starting prenatal care late, missing major milestones, and overusing nonroutine medical services. Early mental health screening and intervention in pregnancy may help improve prenatal outcomes.

Characterization of Patients with Frequent Utilization of the Obstetric Triage Unit: A Retrospective Cohort Study.

This study aimed to identify characteristics of patients with frequent obstetric triage visits ("superusers") compared to those with fewer visits and to evaluate the association of frequent obstetric triage visits with preterm birth and cesarean delivery. This retrospective cohort included patients presenting to the obstetric triage unit at a tertiary care center from March through April 2014. Superusers were defined as individuals having four or more triage visits. Participant characteristics, including demographic, clinical, visit acuity, and health care characteristics of superusers and nonsuperusers, were summarized and compared. In the subset of patients where data were available regarding prenatal care, prenatal visit patterns were analyzed and compared between the two groups. The outcomes of preterm birth and cesarean were compared between groups using modified Poisson regression to control for confounding. Of the 656 patients evaluated in the obstetric triage unit during the study period, 648 patients met the inclusion criteria. Factors associated with frequent triage use included race/ethnicity, multiparity, insurance status, high-risk pregnancy, and a prior preterm birth. Superusers were more likely to present at an earlier gestational age and had a higher proportion of visits for hypertensive disease. Patient acuity scores were not different between the groups. In the subset of patients receiving prenatal care at the institution, prenatal visit patterns were similar. The risk of preterm birth (adjusted risk ratio [aRR]: 1.06; 95% confidence interval [CI]: 0.66-1.70) did not differ between groups; however, the risk of a cesarean delivery was increased in superusers (aRR: 1.39; 95% CI: 1.01-1.92) when compared to nonsuperusers. Superusers, compared to nonsuperusers, have distinct clinical and demographic characteristics and are more likely to be seen in the triage unit at earlier gestational ages. Superusers tended to have a higher proportion of visits for hypertensive disease and had an increased risk of cesarean delivery. · Patients with frequent triage visits did not have an increased risk of preterm birth.. · Patients with frequent triage visits were more likely to undergo cesarean delivery.. · Acuity scales were similar for patients with frequent visits compared to those with few visits..

The additive role of angiogenic markers for women with confirmed preeclampsia

Hypertension complicates 2% to 8% of all pregnancies and is a leading cause of maternal and perinatal morbidity and mortality globally. Given the prognostic role that angiogenic markers play in evaluation of patients with "suspected preeclampsia," the International Society for the Study of Hypertension in Pregnancy incorporated angiogenic imbalance into the 2021 definition of preeclampsia. As women with "suspected preeclampsia" are a heterogeneous group, with some already meeting the diagnostic criteria for preeclampsia, we evaluated whether the soluble fms-like tyrosine kinase-1/placental growth factor ratio adds prognostic value among these women. This study aimed to assess the additive value of soluble fms-like tyrosine kinase-1/placental growth factor ratio when the diagnostic criteria for preeclampsia have already been met. This was a secondary analysis of a prospective cohort study of patients presenting to obstetrical triage with suspected preeclampsia at ≥20+0 weeks' gestation from July 2009 to June 2012 in Boston, United States. Clinicians were masked to soluble fms-like tyrosine kinase-1/placental growth factor ratio results. Clinical records were reviewed for maternal and neonatal care and outcomes. The value of the soluble fms-like tyrosine kinase-1/placental growth factor ratio (≤38, >38, or >85) was assessed for identifying women at low or high risk of evolving into preeclampsia with severe features within 2 weeks of the triage visit, with preeclampsia with severe features being defined by the American College of Obstetricians and Gynecologists (2013 definition). Based on information in obstetrical triage, preeclampsia among triage patients was defined either by: (1) The International Society for the Study of Hypertension in Pregnancy "restrictive" criteria (ie, new-onset hypertension and proteinuria at ≥20 weeks), or (2) The International Society for the Study of Hypertension in Pregnancy "broad" maternal criteria (ie, new-onset hypertension with proteinuria or one/more relevant maternal end-organ complications). Of 1043 patients included, 459 presented at 20+0 to 34+6 weeks and 584 at ≥35+0 weeks. In triage, 25.8% of women with "suspected preeclampsia" already met the preeclampsia criteria based on the International Society for the Study of Hypertension in Pregnancy broad criteria and 22.0% based on the restrictive criteria. In separate multivariable analyses adjusted for gestational age, a soluble fms-like tyrosine kinase-1/placental growth factor ratio >38 was independently associated with preeclampsia with severe features within 2 weeks even after adjusting for preeclampsia diagnosis in obstetrical triage, whether that preeclampsia were defined restrictively (odds ratio, 15.62; 95% confidence interval, 8.91-27.40) or broadly (odds ratio, 14.56; 95% confidence interval, 8.30-25.56). A soluble fms-like tyrosine kinase-1/placental growth factor ratio ≤38 was good at ruling out development of preeclampsia with severe features within 2 weeks among all patients and among those meeting the restrictive or broad definitions of preeclampsia (negative likelihood ratios, ≤0.16), driven by performance of the ratio before 35 weeks (ie, negative likelihood ratio ≤0.12). A soluble fms-like tyrosine kinase-1/placental growth factor ratio >85 was good at ruling-in preeclampsia with severe features within 2 weeks among women with suspected preeclampsia, either before (positive likelihood ratio, 8.20) or after 35 weeks (positive likelihood ratio, 6.00) and fair at ruling-in preeclampsia with severe features within 2 weeks when preeclampsia had already been confirmed in patients at <35 weeks (restrictively positive likelihood ratio, 3.48, or broadly positive likelihood ratio, 3.40). Our findings support the prognostic value of the soluble fms-like tyrosine kinase-1/placental growth factor ratio among patients with confirmed preeclampsia, particularly to identify those both likely and unlikely to progress toward the development of severe features in the next 2 weeks and those who may be most appropriate for expectant and potentially outpatient care. Our findings support the incorporation of angiogenic imbalance into the definition of preeclampsia, particularly at 20-34+0 weeks.

Impact of the COVID-19 Pandemic on Prenatal Care Utilization at a Public Hospital.

The aim of the study is to compare rates of prenatal care utilization before and after implementation of a telehealth-supplemented prenatal care model due to the coronavirus disease 2019 (COVID-19) pandemic. Using electronic medical record data, we identified two cohorts of pregnant persons that initiated prenatal care prior to and during the COVID-19 pandemic following the implementation of telehealth (from March 1, 2019 through August 31, 2019, and from March 1, 2020, through August 31, 2020, respectively) at Grady Memorial Hospital. We used Pearson's Chi-square and two-tailed t-tests to compare rates of prenatal care utilization, antenatal screening and immunizations, emergency department and obstetric triage visits, and pregnancy complications for the prepandemic versus pandemic-exposed cohorts. We identified 1,758 pregnant patients; 965 entered prenatal care prior to the COVID-19 pandemic and 793 entered during the pandemic. Patients in the pandemic-exposed cohort were more likely to initiate prenatal care in the first trimester (46.1 vs. 39.0%, p = 0.01), be screened for gestational diabetes (74.4 vs. 67.0%, p <0.001), and receive dating and anatomy ultrasounds (17.8 vs. 13.0%, p = 0.006 and 56.9 vs. 47.3%, p <0.001, respectively) compared with patients in the prepandemic cohort. There was no difference in mean number of prenatal care visits between the two groups (6.9 vs. 7.1, p = 0.18). Approximately 41% of patients in the pandemic-exposed cohort had one or more telehealth visits. The proportion of patients with one or more emergency department visits was higher in the pandemic-exposed cohort than the prepandemic cohort (32.8 vs. 12.3%, p < 0.001). Increases in rates of labor induction were also observed among the pandemic-exposed cohort (47.1 vs. 38.2%, p <0.001). Rates of prenatal care utilization were similar before and during the COVID-19 pandemic. However, pregnant persons receiving prenatal care during the pandemic entered care earlier and had higher utilization of certain antenatal screening services than those receiving prenatal care prior to the pandemic. · Patients initiated prenatal care earlier during the COVID-19 pandemic.. · Uptake of telehealth services was low.. · Rates of diabetes screening and ultrasound use increased during the pandemic..

Expedited postpartum discharge during the COVID-19 pandemic and acute postpartum care utilization

Background Early postpartum discharges increased organically during the COVID-19 pandemic. It is not known if this ‘natural experiment’ of shorter postpartum hospital stays resulted in increased risk for postpartum readmissions and other acute postpartum care utilization such as emergency room encounters. Objective The objectives of this study were to determine which clinical factors were associated with expedited postpartum discharge and whether the expedited postpartum discharge was associated with increased risk for acute postpartum care utilization. Methods This retrospective cohort study evaluated birth hospitalizations at affiliated hospitals during two periods: (i) the apex of the ‘first wave’ of the COVID-19 pandemic in New York City (3/22/20 to 4/30/20) and (ii) a historical control period of one year earlier (3/22/19 to 4/30/19). Routine postpartum discharge was defined as ≥2 d after vaginal birth and ≥3 d after cesarean birth. Expedited discharge was defined as <2 d after vaginal birth and <3 d after cesarean birth. Acute postpartum care utilization was defined as any emergency room visit, obstetric triage visit, or postpartum readmission ≤6 weeks after birth hospitalization discharge. Demographic and clinical variables were compared based on routine versus expedited postpartum discharge. Unadjusted and adjusted logistic regression models were performed to analyze factors associated with (i) expedited discharge and (ii) acute postpartum care utilization. Unadjusted (ORs) and adjusted odds ratios (aORs) with 95% CIs were used as measures of association. Stratified analysis was performed restricted to patients with chronic hypertension, preeclampsia, and gestational hypertension. Results A total of 1,358 birth hospitalizations were included in the analysis, 715 (52.7%) from 2019 and 643 (47.3%) from 2020. Expedited discharge was more common in 2020 than in 2019 (60.3% versus 5.0% of deliveries, p < .01). For 2020, clinical factors significantly associated with a decreased likelihood of expedited discharge included hypertensive disorders of pregnancy (OR 0.40, 95% CI 0.27–0.60), chronic hypertension (OR 0.14, 95% CI 0.06–0.29), and COVID-19 infection (OR 0.51, 95% CI 0.34–0.77). Cesarean (OR 3.00, 95% CI 2.14–4.19) and term birth (OR 3.34, 95% CI 2.03, 5.49) were associated with an increased likelihood of expedited discharge. Most of the associations retained significance in adjusted models. Expedited compared to routine discharge was not associated with significantly different odds of acute postpartum care utilization for 2020 deliveries (5.4% versus 5.9%; OR 0.92, 95% CI 0.47–1.82). Medicaid insurance (OR 2.30, 95% CI 1.06–4.98) and HDP (OR 5.16, 95% CI: 2.60–10.26) were associated with a higher risk of acute postpartum care utilization and retained significance in adjusted analyses. In the stratified analysis restricted to women with hypertensive diagnoses, expedited discharge was associated with significantly increased risk for postpartum readmission (OR 6.09, 95% CI 2.14, 17.33) but not overall acute postpartum care utilization (OR 2.17, 95% CI 1.00, 4.74). Conclusion Expedited postpartum discharge was not associated with increased risk for acute postpartum care utilization. Among women with hypertensive diagnoses, expedited discharge was associated with a higher risk for readmission despite expedited discharge occurring less frequently.

Activity Monitoring for Toxicity Detection and Management in Patients Undergoing Chemoradiation for Gastrointestinal Malignancies.

Physical activity is associated with decreased hospitalization during cancer treatment. We hypothesize that activity data can help identify and triage high-risk patients with GI cancer undergoing concurrent chemoradiation. This prospective study randomly assigned patients to activity monitoring versus observation. In the intervention arm, a 20% decrease in daily steps or 20% increase in heart rate triggered triage visits to provide supportive care, medication changes, and escalation of care. In the observation group, activity data were recorded but not monitored. The primary objective was to show a 20% increase in triage visits in the intervention group. Secondary objectives were estimating the rates of emergency department (ED) visits and hospitalizations. Crude and adjusted odds ratios were computed using logistic regression modeling. There were 22 patients in the intervention and 18 in the observation group. Baseline patient and treatment characteristics were similar. The primary objective was met, with 3.4 more triage visits in the intervention group than in the observation group (95% CI, 2.10 to 5.50; P < .0001). Twenty-six (65.0%) patients required at least one triage visit, with a higher rate in the intervention arm compared with that in the observation arm (86.4% v 38.9%; odds ratio, 9.95; 95% CI, 2.13 to 46.56; P = .004). There was no statistically significant difference in ED visit (9.1% v 22.2%; P = .38) or hospitalization (4.5% v 16.7%; P = .31). It is feasible to use activity data to trigger triage visits for symptom management. Further studies are investigating whether automated activity monitoring can assist with early outpatient management to decrease ED visits and hospitalizations.

Activity Monitoring for Early Detection and Management of Toxicity in Patients Undergoing Chemoradiation for Gastrointestinal Malignancy

<h3>Purpose/Objective(s)</h3> Higher levels of physical activity assessed by step count have been associated with lower risk of hospitalization during cancer treatment. We hypothesize that it is feasible to use activity data to identify patients undergoing concurrent chemoradiation for gastrointestinal (GI) malignancy who are at high risk for emergency department (ED) visits and hospitalizations, and to successfully trigger and execute triage visits for symptom management. <h3>Materials/Methods</h3> This prospective study randomized patients to activity monitoring versus observation. Each group was provided an activity monitor. If a patient in the intervention arm had 20% decreased activity or 20% increase in heart rate from their baseline, a triage visit was triggered to evaluate and treat symptoms. In the observation group, activity data was recorded but no triage visit was triggered. Baseline step count and heart rate were established during a one-week period between radiation simulation and treatment start. The primary endpoint was to demonstrate an increased rate of triage visits in the activity monitoring group compared to observation. Secondary outcomes included rates of ED visits and hospitalizations. Crude and adjusted odds ratios (OR) were computed using logistic regression modeling. <h3>Results</h3> A total of 40 patients were enrolled on the study: 22 in the intervention group and 18 in the observation group. Primary disease sites included anus (n = 4), gastric/esophagus (n = 14), hepatobiliary (n = 4), pancreas (n = 7), and rectum (n = 11). Median age was 60 years in the intervention arm and 62.5 years in the observation arm (<i>P</i> = 0.69). The median radiation dose and fractionation were similar among the two groups. Average baseline daily step counts were similar in the two groups (5,103 in intervention group vs. 5,668 in observation group, <i>P</i> = 0.43). Average daily step counts decreased from week 1 to week 5 in both groups (-960 steps in observation group and -1,164 steps in the intervention group). There was an increased rate of triage visits in the intervention arm compared to the observation arm (86.4% v 38.9%, OR 9.95, 95% CI 2.12-46.56, <i>P</i> = 0.015). Rates of ED visits and hospitalizations were numerically lower in the intervention group compared to the observation group (9.1% vs 22.2%, <i>P</i> = 0.31; 4.5% vs 16.7%, <i>P</i> = 0.31, respectively). Patients with anal (-1456 steps) cancer showed the largest decrease in mean daily step count over the treatment course. Medical intervention was more common in the intervention group compared to observation (<i>P</i> < 0.001). <h3>Conclusion</h3> This study supports the feasibility of actively monitoring patient's daily step and heart rate data to successfully trigger triage visits for patients at high risk for toxicity. Further studies are ongoing and may support the use of automated activity monitoring to decrease the rates of ED visits and hospitalizations.

Effect of activity monitoring on quality of life in patients with gastrointestinal cancer undergoing chemoradiation.

e18671 Background: Patients undergoing concurrent radiation therapy and systemic therapy often experience significant toxicities, which can adversely affect their quality of life. We sought to determine if activity monitoring and early outpatient intervention could lead to improved quality of life (QoL) in patients with gastrointestinal malignancies undergoing chemoradiotherapy. Methods: In this prospective randomized trial, patients with gastrointestinal malignancies undergoing concurrent chemoradiotherapy were randomized to activity monitoring versus standard of care (observation). Each group was provided a commercially available fitness tracker but only the intervention group was actively monitored. If a patient in the intervention arm had a 20% decrease in step count or 20% increase in heart rate from their baseline, a triage visit was triggered to further evaluate and manage symptoms. In the observation group, step count and heart rate were recorded but no triage visit was triggered. All patients had weekly on treatment visits and access to standard communication methods for symptom management during and after-hour business hours. The primary endpoint was the rate of completed triage visits. QoL was a secondary endpoint and was collected from both arms at radiation simulation (baseline) and weekly during treatment using the EORTC QLQ-C30 (v.3). The mixed model for repeated measures was used for longitudinal analysis of global health status (GHS) and overall QoL scores (range 1-7) to determine the impact of intervention and time on QoL. Results: A total of 40 patients were evaluable in this study: 22 in the intervention group and 18 in the observation group. The primary endpoint was met with an increased rate of triage visits in the active monitoring group compared to the observation group (86.4% vs 39.9%, OR 9.95, 95% CI 2.12 -46.56, p = 0.015). EORTC QLQ-C30 questionnaires were completed by 97.5% of patients. The baseline QoL scores were similar in both arms (mean GHS 5.06 vs 5.50, p = 0.28 and mean QoL 4.98 vs 5.73, p = 0.09 in observation vs intervention group, respectively). There was a trend towards improved mean GHS, and QoL scores in the intervention group at all timepoints, although it did not reach statistical significance. Overall, GHS and QoL scores deteriorated from week 1 to week 6 during treatment in both groups (mean QoL 5.06 to 4.46, p = 0.16 in observation; mean QoL 5.55 to 5.03, p = 0.16 in intervention group). Conclusions: This study supports the feasibility of using activity monitor to actively track step count and heart rate to successfully trigger triage visits for patients at high risk for toxicity. Early outpatient intervention with the use of activity monitoring may improve quality of life in patients undergoing chemoradiotherapy.

1102 Analysis of antepartum obstetric triage utilization at 24 weeks and beyond

Antepartum obstetric triage visits represent a significant consumption of healthcare resources in pregnancy. We sought to understand the nature of antepartum obstetric triage utilization at 24 weeks and beyond which did not result in admission for delivery. This was a retrospective cohort of all women who delivered at or greater than 24 weeks within a single tertiary system between January 2014 and April 2017. We collected baseline characteristics, antepartum course and delivery outcomes. Information regarding all triage visits at 24 weeks and beyond, which did not result in an admission for delivery (either spontaneous or medically indicated), was included. To identify characteristics associated with higher triage utilization, we employed a Poisson intensity model, which assumes the number of recurrent events (triage visits) in non-overlapping time intervals follows a Poisson process. In this way, the intrinsic correlation between events occurred (triage visits) in the same pregnancy are taken into consideration. There were 10,611 pregnancies included in the study for a total of 17,992 triage visits which did not result in admission for delivery. The mean number of triage visits was 1.7 (sd=1.44, range 0-20) per patient, with 9278 (87.4%) pregnancies having at least 1 antepartum triage visit which did not result in delivery. (Figure 1) The most common reason for triage visits was labor evaluation, representing 32.2% (5800) of all triage visits. In the recurrent event model, age, race, marital status, insurance type, parity, history of preterm delivery, and infection in pregnancy, were associated with increased triage utilization. (Table 1) There are a large number of antepartum triage visits at or beyond 24 weeks not resulting in delivery, with a majority of patients using triage at least once prior to presentation for delivery, with the most common reason being labor evaluation. Understanding characteristics associated with increased antepartum triage utilization provides an opportunity to allocate healthcare resources most appropriately in pregnancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

911 Readmission for hypertension among women in a postpartum remote blood pressure monitoring program

The effect of remote postpartum blood pressure (BP) monitoring on readmission has been variable, with studies reporting 0-15% of women being readmitted. Our objective was to describe patterns in postpartum hospital visits and readmission among women enrolled in a remote postpartum BP monitoring program. Retrospective longitudinal evaluation of a text-based blood pressure program (9/2018-8/2019). The program used twice daily reminders and two-way communication on BP for 10 days after hospital discharge. BP was triaged by a Maternal-Fetal Medicine physician. Women diagnosed with chronic hypertension (HTN) or a hypertensive disorder of pregnancy at the time of delivery discharge were included. Clinical data were abstracted from the electronic medical record. The primary outcome was readmission for HTN within 6 weeks of discharge. Bivariate analyses were performed to analyze factors associated with readmission. Monthly readmissions were assessed with a p chart. Of 877 women discharged with remote monitoring, 60 (6.8%) were seen in the obstetric (OB) triage for BP or symptoms of preeclampsia. Twelve (20%) were sent through the program and 48 (80%) presented independently or at the direction of an OB nurse or physician. Eighteen (30.0%) were readmitted, resulting in a readmission rate of 2.1% per year. Median time from delivery to readmission was 6 days (range 3-18). Demographic and clinical factors were not associated with readmission (Table). Triage evaluations initiated through the program were more likely to result in readmission (58.3% vs. 22.9%, RR 2.54 [95%CI 1.26-5.15]). Readmission rates ranged from 0-4.9% per month without significant change over time (Figure). Readmission was infrequent among postpartum women with remote blood pressure monitoring. The majority of triage visits initiated outside the program did not result in readmission, possibly representing unnecessary hospital encounters. Education for providers and patients on triaging BP through the program may result in fewer triage visits, which in turn may lead to fewer readmissions.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

274 Healthcare resource utilization associated with a risk-based thromboprophylaxis protocol in obstetric patients

Venous thromboembolism (VTE) is a preventable cause of maternal morbidity and death. Guidelines advise a risk-based approach to mechanical and pharmacologic VTE prophylaxis (ppx) in obstetric patients, yet routine use of prophylactic, heparin-based anticoagulation is largely unstudied in this population. Our institution adopted a risk-based protocol for heparin-based VTE ppx in obstetric patients in 2016 (Table 1); we evaluated the impact of this protocol on healthcare resource utilization. Retrospective cohort study of all deliveries at a single tertiary-care center from 2013-2018. Deliveries were categorized as pre- (2013-2015; no standardized heparin ppx) and post-protocol (2016-2018; Table 1). Patients receiving anticoagulation for active VTE or high VTE risk were excluded. Healthcare resource utilization outcomes included anticoagulation use, blood transfusion, readmissions, maternity triage visits, imaging tests, and hematologic laboratory studies performed (Table 2). Pre- and post-protocol outcomes were compared with student’s t-, χ2, and Fisher’s exact tests; adjusted odds ratios (95%CI) were calculated with the pre-protocol cohort as reference. Of 24,229 total deliveries, 11,799 (49%) were pre-, and 12,430 (51%) post-protocol. There was a 15-fold increase in anticoagulation use after protocol adoption (15.6% vs 1.2%, p<0.001). This was associated with significantly more red blood cell transfusions (3.8% vs 2.9%, p<0.001) despite more restrictive transfusion practices. Except for an increase in postpartum platelet studies related to institutional platelet monitoring in heparinized women (18.6% vs 15.4%, p<0.001), no significant changes were seen in utilization of any other resources (Table 2). A risk-based protocol for heparin-based ppx is associated with more anticoagulation administration, platelet studies, and blood transfusions. Further studies are needed to evaluate resource allocation versus safety and efficacy of routine risk-based obstetric VTE ppx.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Urgent dental care on a national level during the COVID-19 epidemic.

ObjectiveThis paper aims to report and discuss the organization and statistics of dental care during the COVID‐19 epidemics on the national level in Slovenia, providing helpful information to health policy planners worldwide.Material and methodsDuring an eight‐week lockdown, Emergency Dental Centers (EDCs) were established and coordinated on the national level to treat patients' urgent dental conditions. Telemedicine was used on the first level of triage to reduce contacts between healthcare workers and patients. Weekly coordination between EDCs was supported by real‐time data acquisition on the number of patient visits, prescribed medicine, the number and type of dental procedures, and the usage of personal protective equipment (PPE).ResultsIn EDCs, 27,468 patients were serviced, on average 235 patients per day/million people. The care was provided by 4798 man days of dental health care workers. Except for the first week, treatment and triage visits showed a slight increase. The number of incisions was nearly constant, while the number of extractions increased. A nearly threefold increase was found for emergency endodontic treatments (EET). The number of antibiotic prescriptions demonstrated an increasing trend. Analgesic prescriptions showed a decreasing trend from the beginning of lockdown.ConclusionsThe reorganization and centralization of dental care proved to be an efficient model in Slovenia for the provision of urgent dental care, and the management of the healthcare workforce and PPE. Data from this study may provide helpful information for planning the needs and corresponding resources for the next waves of epidemics of COVID‐19.