Unnecessary Utilization Research Articles

Approaches to Pediatric Chest Pain: A Narrative Review

Chest pain in children and adolescents is a common reason for emergency department visits and referrals to pediatric cardiologists, often driven by parental concern about potential cardiac causes. However, the vast majority of pediatric chest pain cases are benign and non-cardiac in origin. This narrative review examines the etiology, evaluation, and management of pediatric chest pain, emphasizing the importance of a thorough clinical history and physical examination in distinguishing between benign and serious conditions. This review also explores the role of diagnostic tests such as electrocardiograms, chest radiography, and echocardiography, highlighting the need to balance the avoidance of unnecessary tests with the imperative to rule out life-threatening cardiac conditions. Despite the low prevalence of cardiac causes, the variability in diagnostic approaches underscores the need for standardized evaluation algorithms. These could streamline care, reduce unnecessary resource utilization, and minimize anxiety for both patients and their families. Future studies should focus on assessing the effectiveness of such algorithms in improving clinical outcomes and resource management. The findings underscore the importance of a careful, evidence-based approach to the management of pediatric chest pain.

The Rise in Glucagon-Like Peptide-1 Receptor Agonist Related Calls to United States Poison Centers

Abstract Background In 2005, the United States (U.S.) Food and Drug Administration (FDA) approved the first Glucagon-Like Peptide-1 Receptor Agonist (GLP-1RA) as adjunctive therapy to improve glycemic control in type 2 diabetes. In 2021, the FDA approved semaglutide for chronic weight management. We aim to characterize GLP-1RAs related calls to all U.S poison centers (PCs). Methods We conducted a retrospective review of the U.S. National Poison Data System (NPDS) between 2005 and 2023 for all GLP-1RA exposures. All 55 PCs covering the entire U.S. population submit, in near real-time, de-identified case data to NPDS after providing poison exposure management to callers from the general public and health care providers. Results During the study period, U.S. PCs handled 13,692 GLP-1RAs related calls, of which 12,451 were a GLP-1RA single substance exposures. In 2023, PCs received 4,414 GLP-1RA related calls, compared to 234 in 2014 (a twenty-fold increase over 10 years). Seventy three percent of exposures involved females (n = 10,017). The main reasons for exposure were therapeutic errors (n = 10,213; 75%), adverse drug reactions (n = 1,222; 9%) and suspected suicide (n = 557; 4%). Gastrointestinal symptoms, such as nausea (n = 2,913; 23%), vomiting (n = 2,515; 20%), and abdominal pain (n = 593; 5%), and neurological symptoms, including central nervous system depression (n = 191; 1.5%), dizziness (n = 563; 5%) and headache (n = 495; 4%) were the most commonly reported clinical effects in single substance exposures. Hypoglycemia was reported in 431 cases (3.5%), Most single substance exposures were managed outside a healthcare facility (n = 8.573; 69%), and hospital admission was reported in 5% of exposures (n = 601). Conclusions PCs are well positioned to monitor trends in GLP-1RAs human exposures and associated adverse events and therapeutic errors. Based on available data, PCs can manage specific cases-types without referral to the hospital, preventing unnecessary healthcare utilization. Key messages • Poison centers are well positioned to monitor trends in GLP-1RAs adverse events. • Poison centers can prevent unnecessary healthcare utilization.

Association between lifetime criminal legal involvement and acute healthcare utilization in middle-aged and older US adults, 2015-2019.

Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults. Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015-2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates. For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06-1.31) but not older adults (IRR 0.99, 95% CI 0.85-1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08-1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57). Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization.

Community paramedicine program and outcomes of referred coronary artery bypass grafting patients.

Community paramedicine is a field in its infancy. The use of community paramedics has expanded in recent years as an alternative or adjunct to home health in the continued drive to decrease health disparities and complications. In current practice, they function in a position like a home healthcare nurse with an expanded scope of practice, such as providing specialized follow-up care, for example with postoperative care for patients who have undergone major surgery or recent hospitalization. This study assesses if community paramedics are a valid option in reducing rehospitalization of patients who underwent a coronary artery bypass grafting (CABG) procedure. A retrospective chart review between 2021 and 2022 was performed on all patients who underwent CABG in Bismarck, North Dakota, along with obtaining a referral for the community paramedics spanning urban and rural areas. A comparison was made between individuals who saw the community paramedics in their post-care versus those who continued with the standard of care. There were 80 participants and 38 location-matched controls. All variables were found to be statistically insignificant except for the number of walk-in visits (urgent care), in which 7 out of 38 sought medical attention in the controls and 4 out of 80 sought medical attention in the participants. The proportions of inpatient readmission rates and emergency department (ED) visits were similar. Given that paramedicine is in its infancy, the emergence of other variations of the community paramedic certification has brought a discussion of their scope of practice. While walk-in visits, even with the limitations, showed significant improvement with the addition of community paramedics, more research is still needed to show their effectiveness in reducing readmission to hospital. Additionally, the patients who sought help from community paramedics may be more likely than the controls to seek help from medical professionals. This study provided a novel look into the effect that community paramedics can have on patients in urban and rural areas in regard to reducing postoperative complications and minimizing unnecessary advanced healthcare utilization.

Urgent palliative care: An effective intervention to improve end-of-life experience and outcomes for patients with advanced cancer.

203 Background: Early integration of palliative care services for advanced oncology patients has a well-documented benefit on quality-of-life measures including symptom management, quality-of-death measures, cost-effectiveness, care-giver burden, and patient satisfaction metrics. However many barriers exist, including delayed referrals and negative perceptions of hospice/palliative care by patients and families. Furthermore, wait times from referral to visit can vary from weeks to months. For patients with late-stage disease, rapidly advancing disease or symptoms, this delay can lead to unnecessary acute care utilization, impoverished quality-of-life, and discordant end-of-life care. Methods: The CU Cancer Center CARE clinic provides advanced symptom management and urgent care services to oncology patients, often seeing patients with high symptom burden and advanced disease. A recent unpublished case-based analysis demonstrated that patients seen in CARE clinic 4 times or more in a month have a high risk of inpatient mortality within 3 months. In response, the CARE clinic created an urgent palliative care program wherein patients have the ability to see a palliative care provider within 1 week of referral who could provide ongoing advanced symptom management/medication titration and facilitate conversations around goal-concordant care in late-stage illness. A 1-year feasibility pilot took place from 2022-2023. Referrals required patients to meet the following criteria: 1) Not already being seen by an ambulatory palliative care professional; and 2) any of the following: prognosis of weeks without an end-of-life care plan; symptoms likely to require hospitalization if not addressed within a week; or seen in CARE clinic 4 or more times in the last month From 09/2022-08/2023, 55 patients were seen. Outcomes were followed for 3 months following final CARE clinic visit and were compared to patients who had received palliative care referrals from the CARE clinic in the preceding year (9/2021-9/2022). Results: In-hospital deaths, hospital days in the last 30 days of life, and palliative care/hospice involvement were all positively affected in our initial pilot. Notably, in-hospital deaths were reduced by 50%. There was also a 14% increase in deaths with hospice care in the pilot group compared to the control group. Conclusions: Data from this feasibility pilot suggest that urgent palliative care can improve key metrics in oncology quality-of-care, and improve cost effectiveness. Further delineation of the outcomes compared in a rigorously controlled population will further define the relative clinical benefit and fiscal implications of such interventions. Urgent palliative care outcomes. Historical Control (2021-2022) Pilot (2022-2023) N 44 55 Hospitalizations 101 52 Deaths 30 (68%) 40 (72%) Deaths in the Hospital 8 (18%) 5 (9%) Deaths With Hospice Care 21 (47%) 34 (61%)

Improving transitional care after acute myocardial infarction: A scoping review.

Cardiovascular disease remains the leading cause of morbidity and mortality, posing a significant challenge to healthcare systems worldwide. Transitional care interventions, which ensure coordination and continuity of care as patients move between different levels of healthcare, have been shown to reduce unnecessary healthcare utilization and improve patient outcomes. While much attention has been given to transitional care in heart failure, this review aims to map the interventions implemented for patients following an acute myocardial infarction (AMI). A scoping review was conducted following the Joanna Briggs Institute (JBI) methodology, with literature searches performed in the Cochrane, CINAHL, MEDLINE, JBI, and SciELO databases, focusing on publications from 2013 onwards in both Portuguese and English. Seventy-five studies were included, with most combining multiple interventions that contributed to improved cardiovascular health outcomes, including increased adherence to healthy lifestyle behaviors, enhanced medication compliance, and better healthcare self-management. These interventions were effective in reducing cardiovascular-related Emergency Department visits, unplanned 30-day readmissions, and mortality following a first-time myocardial infarction. Key strategies identified included discharge planning, digital health solutions, outpatient care, and healthcare coordination. The findings of this review underscore the need for developing methodologies that enhance the transition of care from hospital to primary care following an AMI. There is an urgent need to design and implement new healthcare programs that integrate discharge interventions, digital health, outpatient care, and healthcare coordination to ensure continuity of care and optimize patient outcomes post-discharge.

Identifying predictors of malingering in psychiatric emergency room settings and evaluating intervention strategies to reduce unnecessary er utilization. Literature review

Malingering in psychiatric emergency room (ER) settings presents a significant challenge, leading to unnecessary healthcare resource utilization and potentially compromising patient care. This literature review examines predictors of malingering and evaluates intervention strategies aimed at reducing unnecessary ER visits. The review identifies a range of predictors, including demographic factors, clinical presentations, historical elements, and motivational aspects, that may indicate malingering. Tools such as structured interviews, validity scales, and behavioral observations are highlighted for their effectiveness in identifying malingering behaviors in psychiatric ERs. The review also explores various intervention strategies, including early identification protocols, staff training programs, and collaborative care models, which have shown promise in mitigating the impact of malingering on healthcare systems. These strategies are important in ensuring that resources are appropriately allocated while maintaining high standards of patient care. However, ethical considerations, particularly the balance between detecting malingering and providing genuine patient care, remain critical challenges. Addressing these issues is essential for improving the efficiency and effectiveness of emergency psychiatric care and ensuring that patients receive appropriate and timely care.

Economic Evaluation of a Novel Lung Cancer Diagnostic in a Population of Patients with a Positive Low-Dose Computed Tomography Result

Background: Early detection of lung cancer is crucial for improving patient outcomes. Although advances in diagnostic technologies have significantly enhanced the ability to identify lung cancer in earlier stages, there are still limitations. The alarming rate of false positives has resulted in unnecessary utilization of medical resources and increased risk of adverse events from invasive procedures. Consequently, there is a critical need for advanced diagnostics after an initial low-dose computed tomography (LDCT) scan. Objectives: This study evaluated the potential cost savings for US payers of CyPath® Lung, a novel diagnostic tool utilizing flow cytometry and machine learning for the early detection of lung cancer, in patients with positive LDCT scans with indeterminate pulmonary nodules (IPNs) ranging from 6 to 29 mm. Methods: A cost offset model was developed to evaluate the net expected savings associated with the use of CyPath® Lung relative to the current standard of care for individuals whose IPNs range from 6 to 29 mm. Perspectives from both Medicare and private payers in a US setting are included, with a 1-year time horizon. Cost calculations included procedure expenses, complication costs, and diagnostic assessment costs per patient. Primary outcomes of this analysis include cost savings per cohort and cost savings per patient. Results: Our analysis showed positive cost savings from a private payer’s perspective, with expected savings of $895 202 311 per cohort and $6460 per patient, across all patients. Scenario analysis resulted in cost savings of $890 829 889 per cohort, and $6429 per patient. Similarly, savings of $378 689 020 per cohort or $2733 per patient were yielded for Medicare payers, across all patients. In addition, scenario analysis accounting for false negative patients from a Medicare payer perspective yielded savings of $376 902 203 per cohort and $2720 per patient. Discussion: The results suggest substantial cost savings, primarily due to reductions in follow-up diagnostic assessments and procedures, and highlight the importance of accurate diagnostic tools in reducing unnecessary healthcare expenditures. Conclusion: CyPath® Lung utilization yields savings for private and Medicare payers relative to the current standard of care in a US setting for individuals with 6 to 20 mm IPNs.

Association of a Novel Electronic Form for Preoperative Cardiac Risk Assessment With Reduction in Cardiac Consultations and Testing: Retrospective Cohort Study.

Preoperative cardiac risk assessment is an integral part of preoperative evaluation; however, there is significant variation among providers, leading to inappropriate referrals for cardiology consultation or excessive low-value cardiac testing. We implemented a novel electronic medical record (EMR) form in our preoperative clinics to decrease variation. This study aimed to investigate the impact of the EMR form on the preoperative utilization of cardiology consultation and cardiac diagnostic testing (echocardiograms, stress tests, and cardiac catheterization) and evaluate postoperative outcomes. A retrospective cohort study was conducted. Patients who underwent outpatient preoperative evaluation prior to an elective surgery over 2 years were divided into 2 cohorts: from July 1, 2021, to June 30, 2022 (pre-EMR form implementation), and from July 1, 2022, to June 30, 2023 (post-EMR form implementation). Demographics, comorbidities, resource utilization, and surgical characteristics were analyzed. Propensity score matching was used to adjust for differences between the 2 cohorts. The primary outcomes were the utilization of preoperative cardiology consultation, cardiac testing, and 30-day postoperative major adverse cardiac events (MACE). A total of 25,484 patients met the inclusion criteria. Propensity score matching yielded 11,645 well-matched pairs. The post-EMR form, matched cohort had lower cardiology consultation (pre-EMR form: n=2698, 23.2% vs post-EMR form: n=2088, 17.9%; P<.001) and echocardiogram (pre-EMR form: n=808, 6.9% vs post-EMR form: n=591, 5.1%; P<.001) utilization. There were no significant differences in the 30-day postoperative outcomes, including MACE (all P>.05). While patients with "possible indications" for cardiology consultation had higher MACE rates, the consultations did not reduce MACE risk. Most algorithm end points, except for active cardiac conditions, had MACE rates <1%. In this cohort study, preoperative cardiac risk assessment using a novel EMR form was associated with a significant decrease in cardiology consultation and testing utilization, with no adverse impact on postoperative outcomes. Adopting this approach may assist perioperative medicine clinicians and anesthesiologists in efficiently decreasing unnecessary preoperative resource utilization without compromising patient safety or quality of care.

Food is Medicine Interventions and Climate Change

Food is Medicine (FiM), also known as Food as Medicine, integrates food and nutrition interventions into health care delivery with the primary goal to improve population health and address diet-related health conditions. To date, there has been little focus on the relation between FiM and climate change despite FiM’s involvement with 2 key drivers of climate change: health care delivery and food systems. FiM may be able to advance lifestyle medicine and population health objectives, as well as mitigate some of the health care and food-related drivers of climate change, by focusing on 4 key areas: (1) Increasing the absolute number and proportion of patients who follow plant-based diets; (2) reducing food waste; (3) reducing unnecessary health care utilization; and (4) lowering transportation-related greenhouse gas emissions related to food procurement. Measuring the ecological impact of FiM alongside clinical, utilization, and financial measures will require a different analytical approach than that used traditionally in health care. Ultimately, thoughtful, data-driven, and urgent interventions that span the food and health care sectors are needed to sustainably support not only FiM, but human, environmental, and planetary health as well.

Evaluation of Screening Results for Vancomycin-Resistant Enterococci: Three-Year Surveillance.

Enterococci are facultative anaerobic, binary, or chained Gram-positive cocci. The gastrointestinal colonization of hospitalized patients is the most important reservoir of vancomycin-resistant enterococci. We aimed to evaluate retrospectively the screening results of vancomycin-resistant enterococci, studied by the simultaneous (real-time) polymerase chain reaction method on rectal swabs of adult and pediatric patients hospitalized in our hospital in 2019-2021. Adult and pediatric patients were included in our study between Jan 2019 and Dec 2021. The results of vancomycin-resistant enterococci, studied with the real-time polymerase chain reaction method from rectal swabs sent from intensive care units and services, were analyzed retrospectively. Isolation of the samples was performed using the Fluorion VRE QLP 1.0 real-time polymerase chain reaction kit (Iontek, Turkey), and detection was performed with the Fluorion Detection System (Iontek, Turkey) real-time polymerase chain reaction device. Overall, 31,725 patients were included in our study. When evaluated in order of years, in 2019, 379 (7%) of 5,389 adults, 322 (7.4%) of 4,003 children, 234 (5.5%) of 4,185 adults in 2020, 157 (2.4%) of 6,499 children, and in 2021, vancomycin-resistant enterococci were detected in 469 (7.5%) of 6,232 adults and 224 (4.1%) of 5,417 children. The prevalence of vancomycin-resistant enterococci is greater in adults, particularly in intensive care units, compared to children. Infection control precautions and training be augmented in high-risk clinics, while the unnecessary utilization of glycopeptides should be limited.

Maryland's Global Budget Revenue Program and Equitable Access to Esophagectomy for Esophageal Cancer

IntroductionWe evaluated equity in access to esophagectomy after Maryland's 2014 “Global Budget Revenue” (GBR) implementation, which equalizes reimbursement rates irrespective of patient insurance and employs an annual hospital revenue ceiling to incentivize reductions in unnecessary resource utilization. We hypothesized that more traditionally underserved patients would undergo surgical treatment for esophageal cancers after GBR. MethodsUsing Maryland's Health Services Cost Review Commission database, we retrospectively analyzed patient demographics, insurance statuses, inflation-adjusted hospital charges, postoperative outcomes, and discharge dispositions for esophagectomies for neoplasms between 2012 and 2018. ResultsFour hundred eighty six patients were included: 22.0% (107) pre-GBR and 78.0% (379) post-GBR. The proportion of African-American patients increased post-GBR (5.6% versus 12.9%, P = 0.035) and subsequently exhibited year-over-year increases. While not statistically significant, the proportion of Medicaid patients increased from 4.7% to 10.0% (P = 0.085). The post-GBR era also saw patients from 10 new counties, six of which were in Maryland's bottom half of counties ranked by median household income, receive operative esophageal cancer treatment without losing representation from pre-GBR counties. Patient age and sex were comparable between the two groups, and there were no significant differences in mortality or 30-day readmissions. Inflation-adjusted hospital charges and length of hospital stay did not appreciably change post-GBR, including after adjusting for age, comorbidities, and surgical approach. ConclusionsGBR increased access to esophagectomy for African-Americans, those insured by Medicaid, and those from lower socioeconomic status counties. Contrary to prior studies of outpatient and emergency room settings, we found the GBR program's goal of reduction of resource utilization and cost were not apparent in this complex surgical population.

Assessing the predictors for paediatric intensive care unit for inter-hospital transfer patients on high-flow nasal cannula or continuous positive airway pressure ventilation at a tertiary Australian paediatric hospital.

The aim of the present study was to assess the predictors of need for paediatric intensive care unit (PICU) admission for inter-hospital transfer patients to a tertiary paediatric hospital ED on high flow (HF) or continuous positive airway pressure (CPAP) ventilation. Single-centre retrospective study of patients transferred to the state's tertiary paediatric hospital. Demographic information and disease management information was obtained. Between October 2021 and September 2022, 53 patients were transferred to the tertiary hospital on HF or CPAP. Of these, 23 required admission to PICU. Those admitted to PICU had a higher median fraction of inspired oxygen than those not admitted (0.4 vs 0.3, respectively, P = 0.013). Patients transported by road (vs flight) were more likely (20/23 patients, RR = 3.15, P = 0.016) to be admitted to PICU (56% vs 18%). Those who had received CPAP prior to or during transfer were more likely to require PICU admission (P = 0.012). We have demonstrated that children who require CPAP to manage their respiratory disease are more likely to require PICU care on transfer to the tertiary paediatric hospital. In addition, those patients being transferred from secondary metropolitan hospitals after a trial of HF are also likely to require PICU care. This suggests that these patients should be directly admitted to PICU, allowing for improved patient experience and flow as well as reducing unnecessary ED resource utilisation.

The Value of Routine Radiography in the Nonoperative Treatment of Metatarsal Fractures: A Retrospective Cohort Study

Although widely used in follow-up treatment protocols, the added value of routine radiographs to clinical decision-making in nonoperative treatment of patients with metatarsal fractures is unclear. This retrospective cohort study aimed to determine whether routine follow-up radiographs contributed to changes in treatment strategies in nonoperative treatment of patients with a metatarsal fracture. Adult (aged ≥ 18 years) patients who received nonoperative follow-up treatment for a metatarsal fracture between May first, 2020 and May second, 2022 were included. All relevant data were extracted from patient records. Radiographs without a documented clinical indication were classified as routine. Outcomes included changes in treatment strategies based on routine radiographs during follow-up treatment and secondarily, changes in treatment strategy based on clinically indicated radiographs. A total of 168 patients were included, with 135 single and 33 multiple metatarsal fractures. During follow-up, 223 radiographs were performed, of which 154 (69%) were routine and 69 (31%) were on clinical indication. Of routine radiographs, 9 (6%) led to a change in treatment which only included additional imaging. No switch to operative treatment or prolonging of immobilization was observed based on routine radiographs. Of clinically indicated radiographs, 16 (23%) led to a change of treatment, including prolonged immobilization (n = 2), additional follow-up appointments (n = 1) and additional imaging (n = 12). Our results show routinely performed radiographs seldom affect treatment strategies in nonoperative treatment of metatarsal fractures, indicating minimal added value to clinical decision-making. Omitting routine radiographs from treatment protocols may contribute to the reduction of unnecessary healthcare resource utilization in clinical practice.

Comparing Outcomes Between Direct and ED Admissions for Neonatal Hyperbilirubinemia.

Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED. Single-center, retrospective study at a large, academic, free-standing children's hospital (2017-2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy. A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy. Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.

Abstract PO1-08-04: Universal Germline Genetic Testing for Breast Cancer: Implementation in a Rural Practice and Impact on Shared Decision Making

Abstract Background: Prior work from our group has shown a high rate of familial breast cancer (BC) among rural BC patients (pts), with 33% reporting &amp;gt; 1 first-degree family members with BC and 55% meeting NCCN germline genetic testing (GGT) criteria (Shelton CH et al. NC Med. J; 2022). In 2018, we increased GGT to include all BC pts and observed: 1) many pts were out-of-criteria per NCCN guidelines but had actionable pathogenic germline variants (PGVs) and 2) knowledge of GGT factored significantly into shared decision making by providers and patients, including for positive and negative results. Beginning in 2019, concurrent with the recommendation from the American Society of Breast Surgeons, we expanded this model of universal GGT to an IRB-approved study to measure the impact of prospective testing on shared decision-making. Herein we report the real-world implementation of universal GGT for patients with BC and genetics-informed treatment decision-making in a rural community practice. Methods: From 2019-2022 all BC pts at a small, rural community hospital were offered GGT. Demographics, clinical features, and GGT results were collected along with clinician-reported clinical recommendations for treatment based on GGT results. Descriptive statistics and two-tailed Fisher’s exact test were employed and significance was set at p&amp;lt; 0.05. Results: 210 BC pts were offered GGT and 192 (91%) underwent testing [97% female, 95% non-Hispanic White, mean age at diagnosis of 62, 75% Stage I], with all but 7 pts completing GGT before primary treatment decisions. 104 (54%) of patients were in-criteria (IC) and 88 (46%) out-of-criteria (OOC) with NCCN GGT guidelines. PGVs were identified in 25 pts (13%) and 15 genes, most commonly BRCA1/2 (5 pts), PALB2 (3), monoallelic MUTYH (3) and ATM, BARD1, CHEK2 (2 pts each). PGV frequencies were 15% in IC and 11% in OOC patients (p=0.495). 46 (24%) pts had only a variant of uncertain significance (VUS) results. 70% of patients had &amp;gt; 1 clinical management change based on their GGT results. Changes in breast surgery, uptake of risk-reducing bilateral salpingo-oophorectomy, surveillance and clinical follow-up were significantly higher in patients with PGV compared to those with VUS/negative results (p &amp;lt; 0.0001). Compared to those with negative results, patients with PGVs in BRCA1 and BRCA2 were significantly more likely to undergo bilateral mastectomy (BLM) while those with PGVs in other genes or with VUS were not significantly more likely to elect for BLM than those with negative results. Clinicians reported that return of GGT reinforced their recommendation for 73/138 (53%) of patients who underwent breast-conserving therapy. GGT results aided in radiation therapy strategy for 54% of pts, most often resulting in dose de-escalation (accelerated fractionation) for negative/VUS pts (Table). Conclusions: Universal GGT for patients with BC was successfully implemented in a rural community practice with &amp;gt;90% uptake. Treatment was enhanced in those with clinically actionable PGVs and de-escalated in those without PGVs. Universal GGT for patients with BC is feasible to implement as the standard of practice within rural populations, enabling optimization of clinical care to patients’ genetic profile and may reduce unnecessary healthcare resource utilization. Universal Germline Genetic Testing for Breast Cancer: Implementation in a Rural Practice and Impact on Shared Decision Making Changes in Radiation Therapy Strategy based on GGT Citation Format: Charles Shelton, Sarah Nielsen, Antonio Ruiz, Lauren Shelton, Karen Freas, Sarah Poll, Brandie Heald, Daniel Pineda-Alvarez, Edward Esplin, Rachel Ellsworth, Hannah Montgomery. Universal Germline Genetic Testing for Breast Cancer: Implementation in a Rural Practice and Impact on Shared Decision Making [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-08-04.

Unscheduled health care interactions in patients with multiple myeloma receiving T-cell redirection therapies

AbstractOutcomes for patients with relapsed/refractory multiple myeloma (R/RMM) have dramatically improved after the development and now growing utilization of B-cell maturation antigen–targeted chimeric antigen receptor (CAR) T-cell therapy and bispecific antibody (BsAb) therapy. However, health care utilization as a quality-of-life metric in these growing populations has not been thoroughly evaluated. We performed a retrospective cohort study evaluating the frequency and cause of unscheduled health care interactions (UHIs) among patients with R/RMM responding to B-cell maturation antigen–targeted BsAb and CAR T-cell therapies (N = 46). This included the analysis of remote UHIs including calls to physicians’ offices and messages sent through an online patient portal. Our results showed that nearly all patients with R/RMM (89%) receiving these therapies required a UHI during the first 125 days of treatment, with a mean of 3.7 UHIs per patient. Patients with R/RMM responding to BsAbs were significantly more likely to remotely contact their physicians’ offices (1.8-fold increase; P = .038) or visit an urgent care center (more than threefold increase; P = .012) than patients with R/RMM responding to CAR T-cell therapies. This was largely due to increased reports of mild upper respiratory tract infections in BsAb patients. Our results underscore the need to develop preemptive management strategies for commonly reported symptoms that patients with R/RMM experience while receiving CAR T-cell or BsAb therapies. This preemptive management may significantly reduce unnecessary health care utilization in this vulnerable patient population.

Post-operative Patient Portal Messaging is Associated With Return to the Emergency Department After Lumbar Spine Surgery.

Retrospective study. To explore the association between patients undergoing lumbar spine surgery who message their care team via an electronic patient portal (EPP) post-operatively and emergency department (ED) visits within 90 days of surgery. Secure patient messaging through electronic patient portals has grown over recent years. Despite its frequent utilization by patients to engage with their care team, its association with clinical outcomes remains unknown in spine surgery. This study was approved by our Institutional Review Board. Inclusion criteria were adults who underwent single-stage lumbar spine surgery between January 2016-June 2023. Patients with incomplete information, multi-stage surgeries, and those who died within 90 days of surgery were excluded. Patient sociodemographic, surgical, hospital readmission, and patient-provider engagement data were collected. A total of 13,135 patients were included. A total of 1,711 patients (13%) had a post-operative ED visit, and 4,791 patients (36%) used the patient portal to send a message after surgery. Sending a post-operative patient message after undergoing lumbar spine surgery was associated with an increased likelihood of having an ED visit that does not lead to readmission (1.29 (1.10-1.53), P = 0.002). Patients with high school degrees were more likely to have an ED visit without readmission (1.33 (1.08-1.65), P = 0.008). Patients at a higher risk of presenting to the ED post-operatively should be identified and may benefit from additional counseling and access to the care team virtually to limit unnecessary healthcare utilization. Focusing on patients who reach out via EPP messaging post-operatively may be a good target patient group to address first. Future research is needed to investigate the possible health literacy and other socioeconomic barriers affecting these patients so that appropriate, more cost-effective resources can be utilized to avoid clinically unnecessary and costly ED visits.

Effectiveness of pharmacist-led medication reconciliation on medication errors at hospital discharge and healthcare utilization in the next 30 days: a pragmatic clinical trial.

Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with well-established clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included-225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. Clinical Trial Registration: https://clinicaltrials.gov/search?id=NCT06207500, identifier NCT06207500.

Two‐step attribute reduction for AIoT networks

AbstractThe evolution of Artificial Intelligence of Things (AIoT) pushes connectivity from human‐to‐things and things‐to‐things, to AI‐to‐things, has resulted in more complex physical networks and logical associations. This has driven the demand for Internet of Things (IoT) devices with powerful edge data processing capabilities, leading to exponential growth in device quantity and data generation. However, conventional data preprocessing methods, such as data compression and encoding, often require edge devices to allocate computational resources for decoding. Additionally, some lossy compression methods, like JPEG, may result in the loss of important information, which has negative impact on the AI training. To address these challenges, this paper proposes a two‐step attribute reduction approach, targeting devices and dimensions, to reduce the massive amount of data in the AIoT network while avoiding unnecessary utilization of edge device resources for decoding. The device‐oriented and dimension‐oriented attribute reductions identify important devices and dimensions, respectively, to mitigate the multimodal interference caused by the large‐scale devices in the AIoT network and the curse of dimensionality associated with high‐dimensional AIoT data. Numerical results and analysis show that this approach effectively eliminates redundant devices and numerous dimensions in the AIoT network while maintaining the basic data correlation.