Unplanned Care Research Articles

Predictors of unplanned emergency hospital admissions among patients aged 65+ with multimorbidity and depression in Northwest London during and after the Covid-19 lockdown in England.

Individuals with multimorbidity have an increased likelihood of using unplanned secondary care including emergency department visits and emergency hospitalisations. Those with mental health comorbidities are affected to a greater extent. The Covid-19 pandemic has negatively impacted on psychosocial wellbeing and multimorbidity care, especially among vulnerable older individuals. To examine the risk of unplanned hospital admissions among patients aged 65+ with multimorbidity and depression in Northwest London, England, during- and post-Covid-19 lockdown. Retrospective cross-sectional data analysis with the Discover-NOW database for Northwest London was conducted. The overall sample consisted of 20,165 registered patients aged 65+ with depression. Two time periods were compared to observe the impact of the Covid-19 lockdown on emergency hospital admissions between 23rd March 2020 to 21st June 2021 (period 1) and equivalent-length post-lockdown period from 22nd June 2021 to 19th September 2022 (period 2). Multivariate logistic regression was conducted on having at least one emergency hospital admission in each period against sociodemographic and multimorbidity-related characteristics. The odds of having an emergency hospitalisation were greater in men than women (OR = 1.19 (lockdown); OR = 1.29 (post-lockdown)), and significantly increased with age, higher deprivation, and greater number of comorbidities in both periods across the majority of categories. There was an inconclusive pattern with ethnicity; with a statistically significant protective effect among Asian (OR = 0.66) and Black ethnicities (OR = 0.67) compared to White patients during post-lockdown period only. The likelihood of unplanned hospitalisation was higher in men than women, and significantly increased with age, higher deprivation, and comorbidities. Despite modest increases in magnitude of risk between lockdown and post-lockdown periods, there is evidence to support proactive case-review by multi-disciplinary teams to avoid unplanned admissions, particularly men with multimorbidity and comorbid depression, patients with higher number of comorbidities and greater deprivation. Further work is needed to determine admission reasons, multimorbidity patterns, and other clinical and lifestyle predictors.

Using case vignettes to study the presence of outcome, hindsight, and implicit bias in acute unplanned medical care: a cross-sectional study.

Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics. First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history. A web-based cross-sectional study in which physicians received case vignettes with a case description and care provided. Physicians were informed about vignette outcomes in a randomized way (no, good, or bad outcome). Physicians rated quality of care for four case vignettes with different outcomes. Subsequently, they received two more case vignettes. Physicians were informed about the past medical history of the patient in a randomized way (somatic or functional). Physicians made treatment and diagnostic decisions for both cases. One hundred ninety-one Dutch emergency physicians (EPs) and general practitioners (GPs) participated. Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests. Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome ( P < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder. Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs.

Identifying key items to be addressed by non-clinical operators to manage out-of-hours telephone triage services for older adults seeking non-urgent unplanned care in Belgium: an e-Delphi study

BackgroundThis study aimed to achieve expert consensus regarding key items to be addressed by non-clinical operators using computer-software integrated medical dispatch protocols to manage out-of-hours telephone triage (OOH-TT) services for calls involving older adults seeking non-urgent unplanned care across Belgium.MethodsA three-part classic e-Delphi study was conducted. A purposive sample of experts specialized in out-of-hours unplanned care and/or older persons across Belgium were recruited as panelists. Eligibility criteria included experts with at least 2 years of relevant experience. Level of consensus was defined to be reached when at least 70% of the panelists agreed or disagreed regarding the value of each item proposed within a survey for the top 10 most frequently used protocols for triaging older adults. Responses were analyzed over several rounds until expert consensus was found. Descriptive and thematic analyses were used to aggregate responses.ResultsN = 12 panelists agreed that several important missing protocol topics were not covered by the existing OOH-TT service. They also agreed about the nature of use (for the top 10 most frequently used protocols) but justified that some modifications should be made to keywords, interrogation questions, degree of urgency and/or flowcharts used for the algorithms to help operators gain better comprehensive understanding patient profiles, medical habits and history, level of support from informal caregivers, known comorbidities and frailty status. Furthermore, panelists also stressed the importance of considering feasibility in implementing protocols within the real-world setting and prioritizing the right type of training for operators which can facilitate the delivery of high-quality triage. Overall, consensus was found for nine of the top 10 most frequently used protocols for triaging older adults with no consensus found for the protocol on triaging patients unwell for no apparent reason.ConclusionOur findings show that overall, a combination of patient related factors must be addressed to provide high quality triage for adults seeking non-urgent unplanned care over the telephone (in addition to age). However, further elements such as appropriate operator training and feasibility of implementing more population-specific protocols must also be considered. This study presents a useful step towards identifying key items which must be targeted within the larger scope of providing non-urgent out-of-hours telephone triage services for older adults seeking non-urgent unplanned care.

Frequency of Prenatal Care Visits: A Core Outcome Set for Prenatal Care Schedules.

Objective: The aim of this study is to develop a core outcome set for the frequency and modality of prenatal care visits. Material and Methods: A consensus development study was conducted in the United States with participants, including 31 health care professionals, 12 public policy members or public health payers, and 18 public members, representing 24 states. A modified Delphi method and modified nominal group technique were utilized. Results: Twenty-one potential core outcomes were developed by combining the outcomes reported in three systematic reviews that evaluated the frequency of prenatal care visits or modality of prenatal visit type (e.g., in person, telemedicine, or hybrids of both). Eighteen consensus outcomes were identified from the Delphi process, following which 10 maternal and 4 neonatal outcomes were agreed at the consensus development meeting. Maternal core outcomes include maternal quality of life; maternal mental health outcomes; the experience of maternity care; lost time; attendance of recommended visits; unplanned care utilization; completion of the American College of Obstetricians and Gynecologists-recommended services; diagnosis of obstetric complications-proportion and timing; disparities in care outcomes; and severe maternal morbidity or mortality. Neonatal core outcomes include gestational age at birth, birth weight, stillbirth or perinatal death, and neonatal intensive care unit admissions. Conclusions: The core outcome set for the frequency and modality of prenatal visits should be utilized in forthcoming randomized controlled trials and systematic reviews. Such application will warrant that in future research, consistent reporting will enrich care and improve outcomes. Clinical Trial Registration number: 2021.

The impact of digital technology in care homes on unplanned secondary care usage and associated costs.

A substantial number of Emergency Department (ED) attendances by care home residents are potentially avoidable. Health Call Digital Care Homes is an app-based technology that aims to streamline residents' care by recording their observations such as vital parameters electronically. Observations are triaged by remote clinical staff. This study assessed the effectiveness of the Health Call technology to reduce unplanned secondary care usage and associated costs. A retrospective analysis of health outcomes and economic impact based on an intervention. The study involved 118 care homes across the North East of UK from 2018 to 2021. Routinely collected NHS secondary care data from County Durham and Darlington NHS Foundation Trust was linked with data from the Health Call app. Three outcomes were modelled monthly using Generalised Linear Mixed Models: counts of emergency attendances, emergency admissions and length of stay of emergency admissions. A similar approach was taken for costs. The impact of Health Call was tested on each outcome using the models. Data from 8,702 residents were used in the analysis. Results show Health Call reduces the number of emergency attendances by 11% [6-15%], emergency admissions by 25% [20-39%] and length of stay by 11% [3-18%] (with an additional month-by-month decrease of 28% [24-34%]). The cost analysis found a cost reduction of £57 per resident in 2018, increasing to £113 in 2021. The introduction of a digital technology, such as Health Call, could significantly reduce contacts with and costs resulting from unplanned secondary care usage by care home residents.

Assessing the impact of a financial incentive and refill reminder program on medication adherence and costs.

Improving medication adherence remains an important goal to improve therapeutic outcomes and lower health care costs. Point-of-sale prescription costs and forgetfulness remain top reasons why patients do not adhere to medications. Programs using both text message-based reminders and financial incentives may encourage patients to refill their prescriptions on time by reducing copays through discounts at the point of sale. Sempre Health, the subject of our analysis, provides both text message refill reminders and a dynamic discount incentive program to improve medication adherence. To evaluate the impact of a financial incentive/refill reminder program on medication adherence and total cost of care for patients taking the antithrombotic agents ticagrelor, apixaban, or rivaroxaban in a large regional health plan. After propensity-score matching on demographics, socioeconomic status, baseline copay, prior pharmacy/medical spend, and morbidity, we compared-using a difference-in-differences analytic approach-adherence (measured by proportion of days covered), unplanned health care utilization, and costs (total cost of care, medical, and pharmacy cost) of health plan members who did and did not enroll in the financial incentive/refill reminder program between February 1, 2019, and October 31, 2021, over 1 and 2 years. Because of differences in patient characteristics, we analyzed patients on ticagrelor (the antiplatelet group), apixaban, and rivaroxaban (the anticoagulant group) separately. There were a total of 1,292 one-to-one program and control propensity-matched patients: 166 each for the antiplatelet group and 480 each for the anticoagulant group. The average age of the anticoagulant group was 62 years; more than 60% were male, and approximately 45% had no prior unplanned care events. In contrast, the average age of the antiplatelet group was 57 years; more than 70% were male, and approximately 21% had no prior unplanned care events. In the antiplatelet group, the proportions adherent (proportion of days covered ≥80%) were 63.3% vs 42.8% (P = 0.0002) for program vs controls. Similarly, in the anticoagulant group, the proportion adherent was 77.9% vs 60.2% (P < 0.0001) for program vs controls. Reflecting improved adherence, costs of apixaban and rivaroxaban increased by $79 per member per month (PMPM) (P < 0.0001), with no statistically significant differences in other costs. Similarly, the cost of ticagrelor increased by $77 PMPM (P = 0.0102) with no statistically significant differences in other costs. Finally, there was a 16% (P = 0.032) reduction in emergency department use for those in the program. The financial incentive and refill reminder program was associated with improved adherence to antithrombotic medications, reduced emergency department use, and increased medication costs, but not in total pharmacy, medical, or total cost of care in both subgroups.

Person-centred quality indicators are associated with unplanned care use following hospital discharge

ObjectivePerformance indicators are used to evaluate the quality of healthcare services. The majority of these, however, are derived solely from administrative data and rarely incorporate feedback from patients who receive...

Long-term catheter management in the community: a population-based analysis of user characteristics, service utilisation and costs in England.

Long-term urinary catheters are problematic and burdensome for patients, carers and health services. Nursing practice to improve the management of long-term urinary catheters has been held back by a lack of evidence to support policy and practice. Little is known about who uses a catheter long term and the resources and costs needed for their management. Understanding these costs will help to target innovations to improve care. There have been no substantial innovations to urinary catheters or their management recently and no publications to characterise users and costs. To describe long-term catheter users and explore catheter-related service use and costs in England. Descriptive information on the characteristics of catheter users and their use of services was obtained from: General Practice records (n = 607), district nursing records (n = 303), questionnaires to patients (n = 333) and triangulated, 2009-2012. Annual service costs (British pounds 2011) were computed. Most catheter users (59.6%) were men, nearly three-quarters (71.2%) were over 70 years and 60.8% used a urethral catheter. Women tended to be younger than men and more likely to use a suprapubic catheter. The services used most frequently over 12 months were general practitioner (by 63.1%) and out of hours services (43.0%); 15.5% accessed Accident and Emergency services for urgent catheter-related care. Hospital use accounted for nearly half (48.9%) of total health service costs (mainly due to inpatient stays by 13.6% of participants); catheter supplies/medications were next most costly (25.7%). Half of all costs were accounted for by 14.2% of users. The median annual cost of services used was £6.38, IQR: £344-£1324; district nursing services added approximately a further £200 per annum. Finding better ways to reduce catheter problems (e.g. blockage, infection) that cause unplanned visits, urgent or hospital care should be a priority to improve quality of life for long-term catheter users and reduce health service expenditure.

Impact of a discharge prescription for dexamethasone on outcomes of children treated in the emergency department for acute asthma exacerbations

Objective To evaluate dexamethasone prescribing practices, patient adherence, and outcomes by dosing regimen in children with acute asthma discharged from the emergency department (ED). Study design Prospective study of children 2–18 years treated with dexamethasone for acute asthma prior to discharge from an urban, tertiary care ED between 2018 and 2022. Demographics, clinical characteristics, ED treatment, and discharge prescriptions were collected via chart review. The exposure was discharge prescription (additional dose) versus no discharge prescription for dexamethasone. The primary outcome was treatment failure, defined as return ED visit, unplanned primary care visit, and/or ongoing bronchodilator use. Secondary outcomes included medication adherence, symptom persistence, quality-of-life, and school/work absenteeism. Outcomes were assessed by telephone 7–10 days after discharge. Results 564 subjects were enrolled; 338 caregivers (60%) completed follow-up. Children were a median age 7 years, 30% Black or African American, 49% Hispanic, and 79% had public insurance. A discharge prescription for dexamethasone was written for 482 (86%) children and was significantly associated with exacerbation severity, number of combined albuterol/ipratropium treatments, and longer length of stay. There was no difference in treatment failure between the discharge prescription and no discharge prescription groups (RR 0.87; 0.67, 1.12), including after adjusting for potential confounders; there was no difference between groups in secondary outcomes. Conclusions Prescription for an additional dexamethasone dose was not associated with reduced treatment failure or improved outcomes for children with acute asthma discharged from the ED. Single, ED-dose of dexamethasone prior to discharge may be sufficient for children with mild to moderate asthma exacerbations.

Predictive value of the National Early Warning Score 2 for hospitalised patients with viral respiratory illness is improved by the addition of inspired oxygen fraction as a weighted variable

ObjectivesThe National Early Warning Score 2 (NEWS2) is validated for predicting acute deterioration, however, the binary grading of inspired oxygen fraction (FiO2) may limit performance. We evaluated the incorporation of...

Treatment Patterns and Healthcare Resource Utilization Among Patients with Triple Class Exposed Multiple Myeloma: A Population-Based Cohort Study

Introduction: Outcomes of patients with relapsed or refractory multiple myeloma (MM) have improved substantially with access to novel therapeutic agents. However, patients with triple class exposed (TCE) MM continue to have poor outcomes. Though newer bispecific antibody and chimeric antigen receptor T-cell immunotherapies have improved outcomes of TCE patients, these therapies are inaccessible outside of clinical trials in many publicly funded healthcare systems, including Canada. This study aimed to describe treatment patterns, outcomes, unplanned health care utilization and quality-of-life impairments of TCE MM patients in Ontario, Canada. These data will provide a crucial benchmark to compare to as novel immunotherapies become available. Methods: This retrospective observational study utilized data from the Institute for Clinical Evaluative Sciences (IC/ES) administrative database, which contains all health records of patients treated within Ontario's publicly funded healthcare system. Drug exposure was determined using the Cancer Activity Level Reporting (ALR) and Ontario Drug Benefit Claims Registry (ODB) databases, housed within IC/ES, which contain data on intravenous and oral MM treatment exposure for standard of care and clinical trial regimens. Patients were defined as TCE if they had prior or current treatment with a regimen containing an immunomodulatory drug (lenalidomide or pomalidomide), a proteasome inhibitor (bortezomib, carfilzomib, or ixazomib), and an anti-CD38 monoclonal antibody (isatuximab or daratumumab). The TCE index regimen was identified as the treatment on which a patient was first identified as having met the TCE definition. Inpatient hospitalization visits did not include planned chemotherapy infusion visits. Quality of life was described using the Edmonton Symptom Assessment System Score with scores ³ 7 corresponding to severe symptoms. Overall survival (OS) was determined using the Kaplan-Meier method. Results: Of the 16,777 patients with a diagnosis of MM between 2007-2021 in Ontario, 1358 patients were classified as TCE during their treatment course. The TCE index regimen was a daratumumab-based regimen in most patients [daratumumab/velcade/dex (n=566, 42%), daratumumab/lenalidomide/dex (n=619, 46%)]. Of the TCE patients, 247 (18%) were still receiving treatment with the TCE index regimen at last follow up, 263 (19%) died without receiving any additional treatment, and 489 (36%) received a subsequent MM treatment after the TCE index regimen. Baseline characteristics of patients (n=489) treated with a subsequent MM regimen after post TCE are summarized in Table 1. The three most commonly administered therapies post TCE were carfilzomib-dexamethasone (n=111, 23%), pomalidomide-dexamethasone (n=77, 16%) and oral cyclophosphamide (n=49, 10%). The next-line treatment regimen was administered in an academic versus community treatment center in 235 (48%) versus 254 (52%) of patients, respectively. The next-line therapy was a clinical trial in only 37 (8%) patients. Regarding healthcare utilization, among TCE patients receiving subsequent therapy, 149 (30%) were evaluated in the emergency department (ED), 126 (26%) were admitted to hospital, and 48 (10%) were referred to palliative care while on treatment with the subsequent therapy. Among patients with available information, the most common severe patient-reported symptoms during the subsequent line of treatment included: tiredness (27%), pain (23%) and overall poor well-being (21%). Additionally, 35% of patients had a ECOG PS of ≥2 on next-line treatment. The median OS patients treated after the TCE index regimen was 1.05 year (95% CI 0.89-1.35) as shown in Figure 1. Of the patients that died during follow up, the majority died in hospital (n=147, 44%) and were referred to palliative care (217, 65%). Conclusion: In this real-world study, we showed that the overall outcomes of TCE MM patients remains poor in Canada, highlighting the urgent need for novel therapies. Furthermore, we demonstrated that TCE patients receiving subsequent therapy had significant unplanned health care utilization and poor quality of life. Future studies will need to assess whether the outcomes, healthcare utilization, and patient-reported quality of life improve as newer immunotherapies become accessible as standard of care treatments within our publicly funded healthcare system.

Maternal outcomes following postpartum autotransfusion of blood lost during vaginal obstetric hemorrhage.

Autotransfusion following vaginal delivery has not been as widely adopted and existing data on this topic are limited to small case series. This is a single-center retrospective matched cohort study. Deliveries exposed to autotransfusion during obstetric hemorrhage were matched to unexposed controls with obstetric hemorrhage who did not receive autotransfusion. The primary outcome was allogeneic transfusion of packed red blood cells. Planned secondary analyses included change in hemoglobin following delivery, composite maternal safety outcomes, and unplanned postpartum health care utilization. Thirty-six deliveries exposed to autotransfusion were matched to 144 unexposed controls. There was no significant difference in allogenic transfusion of packed red blood cells in the patients exposed to autotransfusion red with unexposed controls (adjusted OR 1.1; 95% CI 0.5-2.4). Deliveries that received autotransfusion had a less severe pre- to post-delivery decline in hemoglobin compared with unexposed controls across all values of QBL (p = .003). There were no significant differences in maternal morbidity outcomes evaluated in exposed versus unexposed deliveries. Autotransfusion in cases of vaginal obstetric hemorrhage did not attenuate rates of allogenic packed red blood cell transfusion but did result in a less severe pre- to postdelivery decline in hemoglobin at discharge. Autotransfusion cases did not have any markers of increased maternal morbidity when compared with a control group. These findings support emerging evidence indicating that autotransfusion of blood lost during vaginal obstetric hemorrhage is a safe and potentially effective tool for use in the management of obstetric hemorrhage.

Rate, Timing, and Duration of Unplanned Readmissions Due to Cardiovascular Diseases among Hospitalized Patients with Cancer in the United States.

Cardiovascular disease (CVD) can lead to unplanned care in patients with cancer, which may affect their prognosis and survival. We aimed to compare the rates, timing, and length of stay of unplanned CVD readmission in hospitalized patients with and without cancer. This study used the 2017-2018 Nationwide Readmissions Database to identify adult hospitalized patients with and without cancer. The primary outcome was 180-day unplanned CVD readmission rates. CVD was defined based on a composite variable that included atrial fibrillation, coronary artery disease, cardiomegaly, cardiomyopathy, heart failure, peripheral artery disease, and stroke. For patients readmitted due to CVD, the timing between admissions (based on the mean number of days between index hospitalization and readmission) and length of stay were further identified. After matching, 300,398 patients were included in the two groups. The composite CVD readmission rates were significantly higher in patients with cancer (5.92% vs 4.10%; odds ratio (OR) 1.47, 95% CI 1.44-1.51, p 0.001). Patients with cancer were also associated with shorter mean number of days to composite CVD readmission (60.48 days vs 68.32 days, p 0.001) and longer length of stay of composite CVD readmission (8.21 days vs 7.13 days, p 0.001). These trends were maintained in analyses of the individual CVD. Hospitalized patients with cancer experienced higher rates of unplanned readmission due to CVD, and their CVD readmissions occurred sooner and required longer lengths of stay compared to patients without cancer. Efforts to reduce unplanned CVD readmissions, such as providing optimized chronic post-discharge care, may improve the health outcomes of patients with cancer.

Outpatient encounters, continuity of care, and unplanned hospital care for children and young people with cerebral palsy.

To describe the relationships between outpatient encounters, continuity of care, and unplanned hospital care in children/young people with cerebral palsy (CP). In this population-based data-linkage cohort study we included children/young people with CP identified in the New South Wales/Australian Capital Territory CP Register (birth years 1994-2018). We measured the frequency of outpatient encounters and unplanned hospital care, defined as presentations to emergency departments and/or urgent hospital admissions (2015-2020). Continuity of outpatient care was measured using the Usual Provider of Care Index (UPCI). Of 3267 children/young people with CP, most (n = 2738, 83.8%, 57.6% male) had one or more outpatient encounters (123 463 total encounters, median six outpatient encounters per year during childhood). High UPCI was more common in children/young people with mild CP (Gross Motor Function Classification System levels I-III, with no epilepsy or no intellectual disability), residing in metropolitan and areas of least socioeconomic disadvantage. Low UPCI was associated with four or more emergency department presentations (adjusted odds ratio [aOR] 2.34; 95% confidence interval [CI] 1.71-3.19) and one or more urgent hospital admissions (aOR 2.02; 95% CI 1.57-2.61). Children/young people with CP require frequent outpatient services. Improving continuity of care, particularly for those residing in regional/remote areas, may decrease need for unplanned hospital care. Many children with cerebral palsy use multiple and frequent outpatient services. Better continuity of care is associated with living in metropolitan and less socioeconomically disadvantaged areas. Outpatient service utilization reduces at the time of transition to adult services. High outpatient utilization is associated with unplanned hospital care. Decreased continuity of care is associated with unplanned hospital care.

A pilot observational study of gait changes over time before and after an unplanned hospital visit in long-term care residents with dementia

BackgroundOlder adults with dementia living in long-term care (LTC) have high rates of hospitalization. Two common causes of unplanned hospital visits for LTC residents are deterioration in health status and falls. Early detection of health deterioration or increasing falls risk may present an opportunity to intervene and prevent hospitalization. There is some evidence that impairments in older adults’ gait, such as reduced gait speed, increased variability, and poor balance may be associated with hospitalization. However, it is not clear whether changes in gait are observable and measurable before an unplanned hospital visit and whether these changes persist after the acute medical issue has been resolved. The objective of this study was to examine gait changes before and after an unplanned acute care hospital visit in people with dementia.MethodsWe performed a secondary analysis of quantitative gait measures extracted from videos of natural gait captured over time on a dementia care unit and collected information about unplanned hospitalization from health records.ResultsGait changes in study participants before hospital visits were characterized by decreasing stability and step length, and increasing step variability, although these changes were also observed in participants without hospital visits. In an age and sex-adjusted mixed effects model, gait speed and step length declined more quickly in those with a hospital visit compared to those without.ConclusionsThese results provide preliminary evidence that clinically meaningful longitudinal gait changes may be captured by repeated non-invasive gait monitoring, although a larger study is needed to identify changes specific to future medical events.

Patient-Reported Outcome Measures Associated with Overall Survival and Acute Care Use in Patients with Newly Diagnosed Myelodysplastic Syndrome, Acute Myelogenous Leukemia, or Acute Lymphoblastic Leukemia

Background: There is limited data on the real-world application of patient-reported outcomes (PROs) and their clinical utility in patients with acute leukemias or myelodysplastic syndrome (MDS). While the associations of PROs with clinical outcomes, such as overall survival (OS) and acute care utilization have been established in patients with solid tumors (Basch E et al. JAMA, 2017.318(2):197-198), these same associations are not well known in patients with hematologic malignancies. Objectives: We assessed the characteristics of baseline PRO measurements in patients with newly diagnosed acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL) or myelodysplastic syndrome (MDS) and examined their associations with OS as well as time to acute care use (TAC). Methods: This retrospective cohort study was conducted on patients with newly diagnosed AML, ALL or MDS between 11/2018-02/2022 who were receiving care at our institution and completed a baseline PRO survey within 30 days of therapy initiation. The PRO survey consisted of a 14-question assessment from the National Cancer Institute's PRO Version of The Common Terminology Criteria for Adverse Events. Each of the symptom domains of the survey are measured on a 1-5 Likert scale. OS was defined as time from therapy initiation to the time of death. TAC was defined as time from therapy initiation to first unplanned acute care visit (emergency room visit or unplanned admission). OS curves were estimated using the Kaplan-Meier method and compared using log-rank tests. Cox proportional-hazards regression modeling was used to compare the hazards of death and acute care use between groups. Results: 56 patients were included with a median age of 63 years (range 26-79). The cohort consisted of more males, non-Hispanic Whites, and patients that received intensive initial therapy (Table 1). Fatigue was the most frequently reported symptom (n=49, 87.5%, mean score of 2.90/5 (SD 1.30), with a majority reporting mild or no symptoms (score &amp;lt; 4, n=33, 58.9%) and 28.6% (n=16) reporting more severe symptoms (scores &amp;gt; or = 4). Similarly, most patients in this cohort reported mild or no symptoms in terms of anorexia, anxiety, or sadness (Table 1). In terms of OS, univariate models for the presence of fatigue, anorexia, anxiety, or sadness was not associated with significantly higher hazard of death. On multivariate analyses adjusting for age, sex, and treatment intensity, every point increase in reported fatigue severity was associated with a 41% increased hazard of death (HR 1.41,95% CI: 1.03-1.93). When stratified by fatigue severity (&amp;gt; or = 4 severe vs &amp;lt; or = 3 mild/no symptoms), patients reported severe fatigue had an 145% increased hazard of death compared to those reported mild/no fatigue (HR 2.45 (95% CI: 1.07-5.61) (Figure 1). Multivariate analyses for anorexia, anxiety, and sadness were not associated with significant differences after adjusting for the above covariates, respectively. Fourteen (25.0%) and 24 (42.9%) patients in this cohort had at least one unplanned acute care visit within 30 and 90 days from initiation of therapy, respectively. The median TAC for this cohort was 4.15 months (range 0.60-27.20 months). Univariate regression modeling revealed no differences for any of the PROs examined in this study. Similarly, no differences were observed in multivariate analyses for each of the PROs after adjusting for age, sex, and therapy intensity. Conclusions: Fatigue was the most severe and frequently reported baseline symptom among patients with newly diagnosed acute leukemia or MDS. Patients reporting increased fatigue were found to have a higher hazard of death compared to those who did not after adjusting for age, sex, and treatment intensity. The characteristics and PROs examined in this study were not associated with TAC or predictive of acute care use at different time points from therapy initiation. Future work is needed to understand how PRO data can be used to identify higher-risk patients prior to treatment initiation.

Prospective validation of machine learning-based approaches to predict potentially preventable emergency visits and hospitalizations.

404 Background: Patients undergoing cancer treatment are at risk for unplanned acute care. Early identification of at-risk patients could enable preventative interventions, reducing costs and treatment delays. To address this, the Centers for Medicare &amp; Medicaid Services developed the Chemotherapy Measure (OP-35) to monitor potentially preventable acute care utilization during outpatient treatment. We previously developed machine-learning (ML) models using three approaches: least absolute shrinkage selection operator (LASSO), random forest (RF), and gradient boosted trees (GBT). The models predict risk of an OP-35 qualifying acute care event in the 30-days following a systemic therapy infusion and had good performance in the internal validation cohort, with GBT demonstrating the best predictive ability (receiver operating characteristic area under the curve (ROC-AUC) = 0.805). The aim of this study was to prospectively validate these models in patients undergoing systemic therapy at a single institution. Methods: All three models are being prospectively validated on systemic therapy infusions, including chemo, immuno, biologic, hormone, research and targeted therapies. Assuming a 2% event rate based on our prior data, with an alpha = 0.05 and 84% power, to detect an ROC-AUC of 0.75, validation will run for a total of 8000 infusions, from May 1 to August 21, 2023. We present early findings from May 1 to May 14, 2023 for this prospective validation. Model performance was assessed for calibration based on brier score and predictive ability based on ROC-AUC. Sensitivity and specificity were calculated for the model with the highest ROC-AUC based on a previously determined Youden’s J statistic. Results: This study included 1096 systemic therapy treatments across 957 patients. 21 (1.9%) infusions resulted in an OP-35 qualifying acute care event (3 emergency department visits and 18 hospitalizations). Most events were due to pain, anemia, sepsis, and/or dehydration. All models had good performance, with GBT demonstrating the greatest predictive ability (ROC-AUC = 0.78 [0.67 - 0.88], compared to LASSO (0.76 [0.65-0.85]) and RF (0.70 [0.56-0.81]). GBT also had good calibration (brier score = 0.017 [0.011 - 0.025]) followed closely by LASSO (0.018 [0.011-0.026]) and RF (0.019 [0.012-0.026]). Youden-based cut-off of 0.0249 corresponded to a validation sensitivity of 77.6% and specificity of 61.9%. Conclusions: Early prospective validation of ML models demonstrates accurate predictions of OP-35 qualifying acute care events on a per-infusion basis. The use of computational tools to identify patients at risk for unplanned acute care would enable preventative interventions, reducing costs and treatment disruptions. Prospective validation is ongoing and more comprehensive results will be presented at the meeting.

Establishing purposeful oncology care disparities reduction strategies.

166 Background: Quality thought leaders have noted the oneness of care quality and equity. Yet, quality improvement (QI) often ignores equity. We implemented a holistic approach to quality specifically designed to facilitate equity. We report the components of the approach and how it is being used to address disparities in unplanned acute care events (ACEs) among chemotherapy patients. Methods: We used the Institute for Health Improvement Whole System Quality framework to integrate care equity in an established quality program. We started by stratifying oncology dashboards by race, ethnicity, and language (REAL) as well as other factors (monitoring). We developed and implemented an Umbrella Action Plan Policy that specified an accountability structure to identify and address disparities (planning) and via goal setting (planning), prioritized, developed, and executed action plans to address disparities once identified (improvement). Results: In February 2023 a system-level senior leadership committee charged with priority setting cancer care quality initiatives approved the Umbrella Action Policy. This led to REAL-stratified, quarterly performance reports being shared with senior leadership who voted for this year’s annual goals to include identification and use of rapid cycle testing to eliminate ACE disparities. The organization-level goal engendered central QI coaching resources, established local entity QI teams within each System-affiliated entity with dedicated oncology program (N=6), and formed a learning collaborative across entities. One of each local QI team chose to focus on reducing race-related, language-related, and payor-related (Medicaid) disparities. The other organizations chose otherwise (e.g., age or gender). Teams are using two approaches to identify ACE root causes among target populations: (1) a structured chart abstraction form to search for, among other things, communication breakdowns, gaps in symptom management or other supportive care, and access barriers; and (2) a semi-structured interview guide to engage patients and caregivers for input and suggestions. In September, teams will work collaboratively to identify and execute small tests of change to alleviate identified drivers contributing to ACE disparities. Data from chart abstractions and patient engagement interviews will be shared along with results from tests of change tried to date. Conclusions: Facilitating the identification of disparities via REAL stratified dashboards, leadership teams setting expectations regarding gap closure, and allocation of resources to support local QI teams has focused the quality planning, monitoring, and, to some extent, improvement activities on care equity among marginalized populations. Prescriptively focusing local organization efforts may be needed for appropriate selection of target populations when wanting to infuse REAL equity in QI programming.

S1152 Early Biologic Therapy in Inflammatory Bowel Disease Patients Is Associated With Improved Outcomes and Reduced Unplanned Care - A Nationwide Analysis

S1152 Early Biologic Therapy in Inflammatory Bowel Disease Patients Is Associated With Improved Outcomes and Reduced Unplanned Care - A Nationwide Analysis

Patient-Reported Distress and Acute Care Utilization for Cervical Cancer Patients Undergoing Concurrent Chemoradiation

Although concurrent chemo-radiation (CRT) and brachytherapy (BT) is curative for locally advanced cervical cancer (LACC), it requires complex coordination of care and is associated with treatment-related toxicity. Our objective was to evaluate patient-reported symptoms and social distress in LACC patients undergoing concurrent CRT and BT to determine whether they are predictive of unplanned acute care utilization. Patients with LACC treated with concurrent CRT and BT between 2013-2020 completed the Edmonton Symptom Assessment Scale-revised (ESAS-r; 9 cancer-related symptoms ranked 0-10) and the Social Difficulties Inventory-21 (SDI-21; 21 social issues ranked 0-3) at every visit as part of routine distress screening. Acute care utilization was defined as any unplanned visit to the radiation nursing clinic, urgent care clinic, emergency department or hospitalization within 1 year from starting treatment. A logistic regression model will be used to evaluate associations between ESAS-r and SDI-21 scores and acute care utilization. Among 151 LACC patients, a total of 354 ESAS-r and SDI questionnaires were completed longitudinally. Mean age at diagnosis was 49.9 years (30-90), 44% were FIGO 2B and overall treatment time was 53.6 days (32-135). At baseline, the most prevalent moderate to severe symptoms (ESAS-r score ≥4) were well-being (50%), anxiety (44%), tiredness (43%) and pain (36%). Post-treatment, these persisted in 42%, 27%, 38%, and 26%, respectively. The most common social distress at baseline was financial (33%). Financial distress post-treatment was significantly predictive of worse well-being (OR = 5.80, p<0.06), anxiety (OR = 3.33, p<0.04) and depression (OR = 4.76, p<0.01). Use of acute care within 1 year after starting treatment occurred in 103 patients (68%) for a total of 617 visits: radiation nursing clinic 71.3%, urgent care clinic 4.4%, emergency department 8.3%, hospitalization 16%. On average there were 6.6 visits/patient (0-31), with the average number of days between treatment start and first acute care visit being 17.9 (0-74). Cervical cancer patients undergoing concurrent CRT report prevalent financial distress and moderate to severe symptoms that persist post-treatment. Acute care utilization commonly occurred during treatment, highlighting a time when additional support is needed. Predictive modelling for distress factors resulting in acute care utilization is now underway.