Unplanned Health Care Utilization Research Articles

6687 Indicators of Diabetes Management: Predicting Unplanned Healthcare Utilization and Mortality in a Suburban Integrated Delivery Network

Abstract Disclosure: K.M. Barton: None. J.Y. Yip: None. K.C. Geckeler: None. A. Popelka: None. D.J. Ramsey: None. Purpose: To explore whether patients with diabetes mellitus (DM) who met Comprehensive Diabetes Care Healthcare Effectiveness Data and Information Set (HEDIS) metrics had a reduced likelihood of experiencing unplanned emergency department (ED) visits, hospitalizations, or mortality. Introduction: The prevalence of DM among U.S. adults is approximately 15% and continues to rise. To enhance care for individuals with DM, Comprehensive Diabetes Care HEDIS quality measures have been established. These measures encompass criteria such as blood pressure control, hemoglobin A1c (HbA1c) levels, and the completion of an annual eye examination. However, the connection of these metrics to health outcomes remains insufficiently studied. Methods: This study comprised a retrospective, cross-sectional exploratory analysis of established patients aged 18 years or older with DM receiving primary care within a suburban integrated delivery network (IDN). Multivariate logistic regression was used to analyze patient characteristics, including demographics, sociomedical factors, and biometrics. Outcome variables encompassed one or more unplanned ED visits (including urgent care), one or more unplanned hospitalizations, or mortality within the one-year study period. Results: Out of 28,929 patients with DM, 5293 (18.3%) had ≥1 ED visit, 3725 (12.9%) had ≥1 hospital admission, and 614 (2.1%) died during 2022. After controlling for available demographic and sociomedical factors, patients with poor HbA1c control (considered HbA1c > 9.0) in the year prior were more likely to experience an ED visit in the study year (adjusted odds ratio [aOR] = 1.292, 95% CI, 1.121-1.489, p < 0.001). Patients who achieved HbA1c control (considered HbA1c < 8.0) in the year prior were less likely to experience an ED visit (aOR = 0.845, 95% CI, 0.763-0.936, p = 0.001) and less likely to experience a hospitalization in the study year (aOR = 0.878, 95% CI, 0.779-0.989, p = 0.032). Patients who completed an eye exam in the year prior were less likely to experience a hospitalization (aOR = 0.913, 95% CI, 0.847-0.984, p = 0.017) or die (aOR = 0.694, 95% CI, 0.579-0.831, p < 0.001) in the study year. Finally, patients who completed microalbumin testing in the year prior were less likely to experience an ED visit (aOR = 0.902, 95% CI, 0.84-0.968, p = 0.004), or die (aOR = 0.464, 95% CI, 0.389-0.554, p < 0.001). Conclusion: Achieving HbA1c control in the previous year is linked to decreased likelihood of experiencing an unplanned ED visit or hospitalization. An eye exam in the year prior was associated with decreased likelihood of hospitalization or death. Further research into interventions aimed at enhancing DM management and reducing associated complications may have potential to enhance patient health outcomes while reducing health care costs. Presentation: 6/3/2024

Intra- and Post-procedural Patient-reported Experience Measures and their Correlation with post-ERCP Adverse Events and Unplanned Healthcare Utilization

Background and Study Aims Post-endoscopic retrograde cholangiopancreatography (ERCP) adverse events (AEs) are common, as is unplanned healthcare utilization (UHU). We aimed to elucidate potential associations between intra- and post-procedural patient-reported experience measures (PREMs) and post-ERCP AEs and UHU. Patients and Methods Prospective data from a multi-center collaborative were used. A validated 0-10 Likert-based PREM assessing intra- and post-procedural symptoms was applied to patients following ERCP and protocolized follow-up was performed at 30 days to identify AEs and UHU for reasons not meeting the definitions of any AE. Multivariable logistic regression was conducted using PREM domains as exposures and individual AEs and UHU as outcomes, with a priori selected patient- and procedure-related covariates. Test performance characteristics and odds ratios (ORs) and 95% confidence intervals (95% CIs) for each PREM domain were reported. Results From September 2018 through October 2023, 3,434 ERCPs were included. Post-procedural abdominal pain of >3 was predictive of pancreatitis (OR 3.71, 2.37-5.73), while a score >6 was strongly predictive of perforation (OR 9.54, 1.10-59.37). Post-procedural pain was also predictive of UHU within 30 days when used as a continuous predictor (OR 1.08 per point, 1.01-1.16). Post-procedural pain of >6 demonstrated high negative predictive values and specificities for post-ERCP AEs. Conclusions Patient-reported symptom scores from a simple Likert-based PREM at the time of discharge from ERCP are associated with presentations for pancreatitis, perforation, and UHU within 30 days. Applying PREMs post-ERCP could potentially prevent UHU and/or facilitate earlier management and improved outcomes for patients with post-ERCP AEs.

Social needs and healthcare utilization in NICU graduates.

Unplanned healthcare utilization after neonatal intensive care unit (NICU) discharge challenges families and healthcare systems. The impact of social needs on post-NICU healthcare utilization is underexplored. Our objective was to identify social needs among NICU graduates and examine associations between social needs and post-NICU healthcare utilization. A prospective cohort design was used to screen for social needs and track healthcare utilization among 112 NICU graduates attending a NICU follow-up clinic (2021-2022). Associations between social needs and healthcare utilization were analyzed using non-parametric statistical tests. Of 112 patients screened, 20 (18%) had some social need. Infants with social needs experienced statistically significant higher rates of hospitalizations, overall encounters, and missed appointments. Social needs are associated with increased unplanned healthcare utilization and missed appointments. Addressing these needs during NICU follow-up may improve preventative care attendance and reduce unplanned healthcare use, leading to better outcomes for vulnerable infants and cost-savings for healthcare systems.

The frail-LESS (LEss sitting and sarcopenia in frail older adults) remote intervention to improve sarcopenia and maintain independent living via reductions in sedentary behaviour: findings from a randomised controlled feasibility trial

BackgroundSarcopenia leads to functional disability, dependence in activities of daily living (ADL), and is a key contributor to frailty. Reducing and breaking up sedentary time is associated with improved sarcopenia and frailty-related outcomes. The aim of this study was to determine the feasibility of delivering and evaluating a remote sedentary behaviour intervention to improve sarcopenia and independent living in older adults with frailty.MethodsA two-arm randomised controlled feasibility trial was conducted with a target of 60 older adults (mean age 74 ± 6 years) with very mild or mild frailty. Participants were randomised to the Frail-LESS (LEss Sitting and Sarcopenia in Frail older adults) intervention or usual care control group for six months. The intervention included tailored feedback on sitting, standing and stepping; an education workbook that included goal setting and action planning; one-to-one health coaching; peer support; and a wearable device to self-monitor sedentary behaviour. Participant recruitment (percentage of eligible individuals recruited), retention and data completion rates were used to assess trial feasibility. Acceptability of the trial was explored through interviews and safety was evaluated via unplanned healthcare utilisation and number of falls. Sitting, standing, stepping and sarcopenia were measured to evaluate potential intervention effects.ResultsSixty participants were recruited. Recruitment and retention rates were 72% and 83%, respectively. Completion rates for outcome measures ranged from 70 to 100%. The trial was safe (< 1 fall per participant on average at each timepoint) and trial procedures were acceptable. Descriptive analysis (mean ± SD) showed that daily sitting was 25.1 ± 82.1 min/day lower in the intervention group, and 6.4 ± 60.5 min/day higher in the control group, at 6 months compared with baseline. Hand grip strength and sit-to-stand score were improved by 1.3 ± 2.4 kg and 0.7 ± 1.0, respectively, in the intervention group.ConclusionsThis study demonstrates the feasibility and safety of delivering and evaluating a remote intervention to reduce and break up sitting in older adults with frailty. The intervention showed evidence towards reducing daily sitting and improving sarcopenia, supporting its evaluation in a definitive randomised controlled trial.Trial registrationISRCTN registry (registration number: ISRCTN17158017). Registered 6th August 2021.

Predictors of Unplanned Health Care Utilization Among Children with Inflammatory Bowel Disease in a Rural Region of the Southeastern US.

Pediatric Inflammatory Bowel Disease (IBD) imposes significant healthcare costs and strains emergency services. This study aimed to identify factors associated with unplanned healthcare usage among children with IBD in a rural, medically underserved region in the southeastern United States. In this retrospective cohort study, we analyzed children (<18years) with moderate or severe IBD followed at an academic pediatric gastroenterology clinic between 2016 and 2021. Each planned visit was treated as a separate observation, and patients were followed after each planned visit until the occurrence of the earliest unplanned healthcare event, until the next planned visit, or until censoring. In our analysis of 471 planned visits from 70 children with IBD, we observed 84 (18%) unplanned visits within 12months, with 39 of these visits related to IBD. Unplanned visits occurred at a median interval of 39 days, predominantly to the emergency department (ED). Multivariate Cox proportional hazards analysis revealed a higher hazard of unplanned visits among female patients, individuals with elevated C-reactive protein levels and anemia, those covered by Medicaid insurance, and those residing closer to the clinic. This study elucidates the challenges faced by children with IBD in rural settings. By identifying factors associated with unplanned healthcare utilization, we can better pinpoint patients who may benefit from targeted interventions to reduce such visits.

The impact of patient engagement on patient safety in care transitions after cancer treatment: Protocol for a systematic review and meta-analysis.

Transitions of care after cancer treatment pose a major challenge for patient safety as adverse events and unplanned healthcare utilization occur frequently. At this point, patient and family engagement (PFE) is particularly valuable since patients and their families experience various challenges along this pathway, such as changing roles and recurrent needs to navigate across structural gaps between different services. However, there is currently a lack of evidence on the impact of PFE on patient safety in transitions after cancer treatment. To systematically review and synthesize evidence on effects of different PFE interventions on patient safety in the transition of care after cancer treatment. This protocol for a systematic review with meta-analysis follows PRISMA-P guidelines. A comprehensive database search will be conducted in MEDLINE, EMBASE, CENTRAL, CINAHL, and APA PsycInfo. Trial registries and grey literature will be searched, forward and backward citation tracking will be performed. Trials with prospective, longitudinal, interventional study designs will be included if they evaluate PFE interventions on patient safety outcomes (primary outcomes: healthcare utilization, patient harm, adherence, patient experience; secondary: quality of life, distress); eligible studies need to survey patients with any oncological disease during or after transition following cancer treatment. Results will be synthesized narratively and meta-analytically using a random-effects model. Risk of bias will be assessed using the Cochrane RoB-2 and revised JBI critical appraisal tool. The certainty of evidence will be judged according to the GRADE approach. Robust evidence of effectiveness is needed to establish PFE interventions for patient safety in care transitions for oncological patients. This review will allow evidence-based conclusions about types and effects of different PFE interventions for transitional safety in oncology care and inform stakeholders in designing sustainable PFE activities. PROSPERO (CRD42024546938), OSF (doi.org/10.17605/OSF.IO/9XAMU).

Expedited versus standard postpartum discharge in patients with hypertensive disorders of pregnancy and its effect on the postpartum course

BackgroundHospital stay after an uncomplicated delivery is typically 2 days for vaginal birth and 3 days for cesarean birth. Health maintenance organizations and third-party payers have encouraged shorter maternity stays. The safety of earlier discharge is unclear particularly when it comes to patients diagnosed with hypertensive disorders of pregnancy (HDP). ObjectiveTo examine whether expedited discharge amongst patients with HDP will have a negative effect on postpartum readmission rate and blood pressure related complications. Study designThis was a single academic center retrospective cohort study of patients with HDP (gestational hypertension, preeclampsia, or chronic hypertension) for 2 epochs: 2015–2018, prior to implementation of an expedited discharge policy, and 2019–2020 after hospital wide implementation of expedited postpartum discharge. The expedited discharge policy entailed patients being discharged home as soon as day 1 after a vaginal delivery and day 2 after a cesarean delivery. The primary outcome was unplanned health care utilization postpartum, defined as emergency department (ED) visits, unscheduled clinic visits, and hospital readmission. Secondary outcomes were planned postpartum visits attendance, antihypertensive medication initiation after discharge, and blood pressure control throughout the first year. Bivariable and multivariable logistic regression analyses were run to evaluate the association between expedited discharge and primary and secondary outcomes. ResultsA total of 1,441 patients were included in the analysis. There were no statistically significant differences in the rate of unplanned health care utilization (11.3% in the standard postpartum discharge group vs. 13.8% in the expedited discharge group, P=.17). Systolic and diastolic blood pressures did not differ between the groups at 1–2 weeks, six weeks, and one year postpartum. Patients in the expedited discharge group were more likely to attend the 1–2-week postpartum blood pressure check (58.7% vs. 51.7%, P=.02, adjusted OR 1.33, 95% CI 1.08–1.77). Other secondary outcomes did not differ between the two cohort groups. ConclusionIn this single academic center study, expedited discharge after delivery in patients with HDP was not associated with a higher rate of unplanned healthcare utilization postpartum.

High risk populations for unplanned healthcare utilization following ostomy construction

BackgroundPatients with a new ostomy have high rates of unplanned healthcare utilization (UPHU). We used machine learning to assess which factors contributed the most to UPHU after ostomy construction. MethodsWe retrospectively studied new ostomy patients between 2018 and 2021 ​at a single institution. The primary outcome was UPHU within 60 days of discharge. Factors that contributed the most to UPHU were assessed using a classification tree machine learning method. ResultsAmong 318 patients, 30.8 ​% of patients had an UPHU event. The classification tree identified diabetes mellitus as the most important factor associated with UPHU: 56 ​% of diabetics had UPHU. Smoking history was the next most important factor: 77 ​% of diabetics who smoked had UPHU. Patients who had diabetes, smoked, and had chronic kidney disease had the highest UPHU rate at 86 ​%. DiscussionUnplanned healthcare utilization after ostomy construction is highest among patients with diabetes, smoking history, and chronic kidney disease.

The burden of significant pain in the cirrhosis population: Risk factors, analgesic use, and impact on health care utilization and clinical outcomes.

We aimed to characterize pain and analgesic use in a large contemporary cohort of patients with cirrhosis and to associate pain with unplanned health care utilization and clinical outcomes in this population. We included all patients with cirrhosis seen in UCSF hepatology clinics from 2013 to 2020. Pain severity and location were determined using documented pain scores at the initial visit; "significant pain" was defined as moderate or severe using established cutoffs. Demographic, clinical, and medication data were abstracted from electronic medical records. Associations between significant pain and our primary outcome of 1-year unplanned health care utilization (ie, emergency department visit or hospitalization) and our secondary outcomes of mortality and liver transplantation were explored in multivariable models. Among 5333 patients with cirrhosis, 32% had a nonzero pain score at their initial visit and 25% had significant (ie moderate/severe) pain. Sixty percent of patients with significant pain used ≥1 analgesic; 34% used opioids. Patients with cirrhosis with significant pain had similar Model for End-Stage Liver Disease-Sodium scores (14 vs. 13), but higher rates of decompensation (65% vs. 55%). The most common pain location was the abdomen (44%). Patients with abdominal pain, compared to pain in other locations, were more likely to have decompensation (72% vs. 56%). Significant pain was independently associated with unplanned health care utilization (adjusted odds ratio: 1.3, 95% CI: 1.1-1.5) and mortality (adjusted hazard ratio: 1.4, 95% CI: 1.2-1.6). Pain among patients with cirrhosis is often not well-controlled despite analgesic use, and significant pain is associated with unplanned health care utilization and mortality in this population. Effectively identifying and treating pain are essential in reducing costs and improving quality of life and outcomes among patients with cirrhosis.

Clinical trial participation and end-of-life care among older adults: A multi-center longitudinal observational cohort analysis of 121,717 patients with cancer.

11181 Background: Patients’ access to clinical trials remains significantly disparate across the US &amp; world. Complex drivers, some rooted in evidence while others in perceptions, impact shared decision making about trial participation esp in older adults (65y+). To that end, we investigated clinical trial participation (CTP) and unplanned healthcare utilization &amp; hospice use in patients w cancer. Methods: We queried the prospective longitudinal observational cohort of all patients with cancer receiving care at any of the 323 practice locations of 14 multi-site community cancer centers across 11 US states, all within the US Oncology Network and participating in the Oncology Care Model (OCM), an alternative payment model pilot from CMS to promote quality cancer care while reducing costs. We extracted data from OCM episode claims, medical records from 7/1/17-6/30/22 and used propensity score matching by time period, age, gender, date of death, cancer type to identify matched episodes for further stratification by CTP, to compare hospice care &amp; unplanned ER utilization by non-trial usual care vs CTP. Results: Overall, 121,717 pts received cancer care across 282,604 OCM care episodes in the community during this 5-yr period. Most (94%) were older adults aged 65y+ with breast, lung, multiple myeloma being the most common cancers. Of 121,717 pts, 4800 (3.9%) participated in a cancer treatment clinical trial in at least one care episode. Analysis of the 13,260 propensity score-matched episodes (6630 usual care vs 6630 CTP) shows: 1. ER/Observation visits: Patients on clinical trials did nothave any more ER/Obs visits vs usual care (ER/Obs episodes: CTP 23.4%, usual care 22.3%, p0.11). 2. Hospitalizations: The proportion of care episodes with hospitalization was higher in CTP vs usual care (25.9% vs 21.9%, p&lt;0.001). 3. Hospice enrollment: Patients on clinical trials were no less likely to enroll in hospice &gt;3 days prior to death, compared to non-trial usual care cohort (CTP 56.8%, usual care 52.6%, OR 1.18, p 0.13). Furthermore, median duration of hospice in patients on trials was not different from usual care (CTP 8 days, usual care 9 days, p 0.16). Conclusions: Our findings show that while more hospitalizations were observed, clinical trials participation is not associated with suboptimal end of life care outcomes pertaining to hospice enrollment &amp; duration as well as unplanned ER/healthcare utilization. Further efforts to integrate access to clinical trials and evidence-based supportive/palliative care in a scalable sustainable model of goal-concordant, patient-center cancer care are ongoing. CMMI Disclaimer: The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.

Impact of Race in Missed Appointments in Pediatric Neurology Resident Clinic at a Large Tertiary Medical Center.

Missed medical appointments are a common problem across specialties. The discontinuity of care leads to unplanned health care utilization, increased costs, and poor health outcomes. Previous studies evaluating pediatric epilepsy have shown significant socioeconomic barriers to care. In several specialties, resident clinic no-show rates are higher than faculty clinics because of socioeconomic barriers. We sought to understand the relationship between race, socioeconomic factors, and missed appointments in a pediatric neurology resident clinic at a large tertiary care hospital. Resident clinic encounters for 1 year were extracted and analyzed for missed appointments, socioeconomic factors, and health care utilization. We found that missed appointments occur for 1 in 5 patients and correlate with socioeconomic factors (eg, income and insurance) and race. Race was a more significant factor than socioeconomic factors for missed appointments. These results provide areas to target and track interventions to improve health outcomes in children in pediatric neurology clinics.

Using an mHealth approach to collect patient-generated health data for predicting adverse health outcomes among adult survivors of childhood cancer.

Cancer therapies predispose childhood cancer survivors to various treatment-related late effects, which contribute to a higher symptom burden, chronic health conditions (CHCs), and premature mortality. Regular monitoring of symptoms between clinic visits is useful for timely medical consultation and interventions that can improve quality of life (QOL). The Health Share Study aims to utilize mHealth to collect patient-generated health data (PGHD; daily symptoms, momentary physical health status) and develop survivor-specific risk prediction scores for mitigating adverse health outcomes including poor QOL and emergency room admissions. These personalized risk scores will be integrated into the hospital-based electronic health record (EHR) system to facilitate clinician communications with survivors for timely management of late effects. This prospective study will recruit 600 adult survivors of childhood cancer from the St. Jude Lifetime Cohort study. Data collection include 20 daily symptoms via a smartphone, objective physical health data (physical activity intensity, sleep performance, and biometric data including resting heart rate, heart rate variability, oxygen saturation, and physical stress) via a wearable activity monitor, patient-reported outcomes (poor QOL, unplanned healthcare utilization) via a smartphone, and clinically ascertained outcomes (physical performance deficits, onset of/worsening CHCs) assessed in the survivorship clinic. Participants will complete health surveys and physical/functional assessments in the clinic at baseline, 2) report daily symptoms, wear an activity monitor, measure blood pressure at home over 4 months, and 3) complete health surveys and physical/functional assessments in the clinic 1 and 2 years from the baseline. Socio-demographic and clinical data abstracted from the EHR will be included in the analysis. We will invite 20 cancer survivors to investigate suitable formats to display predicted risk information on a dashboard and 10 clinicians to suggest evidence-based risk management strategies for adverse health outcomes. Machine and statistical learning will be used in prediction modeling. Both approaches can handle a large number of predictors, including longitudinal patterns of daily symptoms/other PGHD, along with cancer treatments and socio-demographics. The individualized risk prediction scores and added communications between providers and survivors have the potential to improve survivorship care and outcomes by identifying early clinical presentations of adverse events.

Emergency department visits and hospital readmissions after a deprescribing intervention among hospitalized older adults.

Deprescribing is the planned/supervised method of dose reduction or cessation of medications that might be harmful, or no longer be beneficial. Though benefits of deprescribing are debatable in improving clinical outcomes, it has been associated with decreased number of potentially inappropriate medications, which may potentially reduce the risk of adverse events among hospitalized older adults. With unclear evidence for deprescribing in this population, this study aimed to examine time-to-first unplanned healthcare utilization, which included 90-day emergency department (ED) visits or hospital readmission and associated predictors, during a deprescribing intervention. A secondary data analysis of a clinical trial (Shed-MEDS NCT02979353) was performed. Cox regression was used to compare the time-to-first 90-day ED visit/readmission/death from hospital discharge for the intervention and control groups. Additionally, we performed exploratory analysis of predictors (comorbidities, functional health status, drug burden index (DBI), hospital length of stay, health literacy, food insecurity, and financial burden) associated with the time-to-first 90-day ED visit/readmission/death. The hazard of first 90-day ED visits/readmissions/death was 15% lower in the intervention versus the control group (95% CI: 0.61-1.19, p = 0.352, respectively); however, this difference was not statistically significant. For every additional number of comorbidities (Hazard ratio (HR): 1.12, 95% CI: 1.04-1.21) and each additional day of hospital length of stay (HR: 1.04, 95% CI: 1.01-1.07) were significantly associated with a higher hazard of 90-day ED visit/readmission/death in the intervention group; whereas for each unit of increase in pre-hospital DBI score (HR: 1.08 and HR 1.16, respectively) was significantly associated with a higher hazard of 90-day ED visit/readmission/death in the control group. The intervention and control groups had comparable time-to-first 90-day ED visit/readmission/death during a deprescribing intervention. This finding suggests that deprescribing did not result in a higher risk of ED visit/readmission/death during the 90-day period following hospital discharge.

Healthcare burden of cognitive impairment: Evidence from a Singapore Chinese health study.

Cognitive impairment (CI) raises risks for unplanned healthcare utilisation and expenditures and for premature mortality. It may also reduce risks for planned expenditures. Therefore, the net cost implications for those with CI remain unknown. We examined differences in healthcare utilisation and cost between those with and without CI. Using administrative healthcare utilisation and cost data linked to the Singapore Chinese Health Study cohort, we estimated regression-adjusted differences in annual healthcare utilisation and costs by CI status determined by modified Mini-Mental State Exam. Estimates were stratified by ex ante mortality risk constructed from out-of-sample Cox model predictions applied to the full sample, with a separate analysis restricted to decedents. These estimates were used to project differential healthcare costs by CI status over 5 years. Patients with CI had 17% higher annual cost compared to those without CI (SGD4870 versus SGD4177, P<0.01). Accounting for the greater mortality risk, individuals with CI cost 9% to 17% more over 5 years, or SGD2500 (95% confidence interval 1000-4200) to SGD3600 (95% confidence interval 1300-6000) more, depending on their age. Higher cost was mainly due to more emergency department visits and subsequent admissions (i.e. unplanned). Differences attenuated in the last year of life when costs increased dramatically for both groups. Ageing populations and higher rates of CI will further strain healthcare resources primarily through greater use of emergency department visits and unplanned admissions. Efforts should be made to identify at risk patients with CI and take appropriate remediation strategies.

Role of Socioeconomic Conditions in Unplanned Healthcare Utilization for Patients with Migraine (P5-4.008)

Role of Socioeconomic Conditions in Unplanned Healthcare Utilization for Patients with Migraine (P5-4.008)

Ambulatory Anorectal Surgery: Unplanned Healthcare Utilization - An Observational Study

Abstract Background: In contemporary medical practice, ambulatory anorectal surgeries have become the standard for proctological procedures. The rate of unplanned healthcare utilization following these procedures in our hospital is unknown. Objectives: This study aims to assess the incidence of unplanned healthcare utilization following ambulatory anorectal surgeries. Design: A retrospective observational study. Setting: University Hospital of Antwerp. Materials (Patients) and Methods: Patients who underwent ambulatory anorectal surgeries during a period of three years, from 2017 to 2019. Sample Size: One hundred and twenty-eight patients. Main Outcome Measures: The incidence of unplanned medical healthcare utilization. Results: Among the 124 patients included in the study, 55 (44.4%) sought medical attention from the emergency department or their general practitioners within the first 30 postoperative days. The reasons for these unplanned returns varied: 16 patients (29.6%) experienced wound problems, 15 patients (27.8%) reported postoperative pain, four patients (6.7%) encountered administrative issues, seven patients (13%) sought information or reassurance, and six patients (11.1%) had other reasons. Notably, no significant risk factors associated with unplanned returns were identified. Conclusions: Nearly half of the patients who underwent ambulatory anorectal surgery sought medical care before their scheduled follow-up appointments, indicating a need for enhanced preoperative and postoperative patient counseling. In addition, earlier follow-up consultations and a review of pain medication prescriptions must be considered. Limitations: Retrospective design constraints leading to possible data exclusions. Conflict of Interest: The authors have no conflict of interest to declare.

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.

Association between patient activation and delayed discharge in elective laparoscopic cholecystectomy: A prospective cohort analysis

BackgroundImproving patient activation may be an effective way to reduce healthcare costs and improve patient outcomes after surgery. ObjectiveTo determine whether preoperative patient activation is associated with delayed discharge (i.e., length of stay >24 h) after elective laparoscopic cholecystectomy. Postoperative symptoms, unscheduled access to healthcare facilities within seven days of surgery, unplanned hospital readmissions, and postoperative complications were analyzed as secondary outcomes. DesignThis cohort study was a secondary analysis of the DeDiLaCo study (Delayed Discharge after day-surgery Laparoscopic Cholecystectomy) collecting data of patients undergoing elective laparoscopic cholecystectomy during 2021 in Italy. Data was analyzed from June 2022 to April 2023. Setting90 Italian surgical centers participating in the study. Participants4708 adult patients with an instrumental diagnosis of gallbladder disease and undergoing laparoscopic cholecystectomy. Patient activation was assessed using the Italian translation of Patient Activation Measure in the preoperative setting. ResultsOf 4532 cases analyzed the median (IQR) Patient Activation Measure score was 80.3 (71.2–92.3). Participants were on average 55.5 years of age and 58.1 % were female. Two groups based on the activation level were created: 270 (6 %) had low activation, and 4262 had high activation. The low activation level was associated with the likelihood of delayed discharge (odds ratio [OR] 1.47, 95 % CI, 1.11–1.95; P = .008), higher symptom burden (OR 1.99, 95 % CI 1.49–2.66, P < .0001), and unplanned healthcare utilization within seven days after hospital discharge (OR 1.85, 95 % CI, 1.29–2.63; P = .001). There was no difference between the high and low activation groups in the incidence of postoperative complications (OR 1.28, 95 % CI, 0.95–1.73; P = .10) and hospital readmission after discharge (OR 0.95, 95 % CI, 0.30–3.05; P = .93). ConclusionsOur results suggest that patients with low activation have 1.47 times the risk of delayed discharge compared with patients with higher activation, almost twice the risk of the onset of postoperative symptoms, and 1.85 times the risk of unscheduled use of hospital services. Screening for patient activation in the preoperative setting could not only identify patients not suitable for early discharge, but more importantly, help physicians and nurses develop tailored interventions.

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.

Utility of Postoperative Phone Calls in Reducing Unplanned Health Care Utilization

IntroductionPostoperative phone calls ideally proactively identify concerns. This study aimed to determine whether postoperative phone calls after elective outpatient pediatric urology surgery were associated with differences in postoperative healthcare utilization. MethodsThis retrospective cross-sectional study included patients undergoing elective outpatient pediatric urologic surgery in selected months of 2019-2021. Data were abstracted on patient demographics, postoperative call completion, number and timing of parent-initiated calls within 30 d, concerns for parent-initiated calls, and timing and indication for emergency department visits within 30 d. Patients with and without completed postoperative calls were compared. ResultsOf 1494 patients, 416 (38.6%) had completed postoperative phone calls; 1078 (61.4%) did not. Calls were more likely to be completed in more disadvantaged areas (Area Deprivation Index deciles 9-10; odds ratio [OR] = 3.87, 95% confidence interval [CI]: 2.70-5.54, P < 0.0001). Overall, the proportions of patients seeking emergency care within 30 d (3.6% versus 4.0%, OR = 0.90, 95% CI: 0.49-1.64, P = 0.73) and with parent-initiated phone calls (31.7% versus 31.3%, OR = 1.02, 95% CI: 0.80-1.20, P = 0.86) were similar in patients with and without postop calls completed. For children in less disadvantaged areas (Area Deprivation Index decile 1-2), the likelihood of a parent-initiated call was higher when postop calls were completed (47.8% versus 33.6%, OR = 1.79, 95% CI: 1.15-2.79, P = 0.01). ConclusionsRoutine postoperative phone calls within 72 h of outpatient pediatric urologic surgery are not associated with decreased overall postoperative health care utilization, and in some cases are associated with an increase in calls to clinic. Defining patient and provider expectations for postoperative contact may make postoperative calls more useful.