Urban Academic Institution Research Articles

Diagnosis Related Groups of Patients Admitted from an Urban Academic Medical Center to a Virtual Hybrid Hospital-at-Home Program.

The diagnosis related group (DRG) is used as an economic patient classification system based on clinical characteristics, hospital stay, and treatment costs. Mayo Clinic's virtual hybrid hospital-at-home program, advanced care at home (ACH), offers high-acuity home inpatient care for a variety of diagnosis. This study aimed to determine the DRGs admitted to the ACH program at an urban academic center. A retrospective study was performed on all patients discharged from the ACH program at Mayo Clinic Florida from July 6, 2020, to February 1, 2022. DRG data were extracted from the Electronic Health Record (EHR). Categorization of DRG was done by systems. The ACH program discharged 451 patients with DRGs. Categorization of the DRG demonstrated that the most frequent code assigned corresponded to respiratory infections (20.2%), followed by septicemia (12.9%), heart failure (8.9%), renal failure (4.9%), and cellulitis (4.0%). The ACH program covers a wide range of high-acuity diagnosis across multiple medical specialties at its urban academic medical campus, including respiratory infections, severe sepsis, congestive heart failure, and renal failure, all with major complications or comorbidities. The ACH model of care may be useful in taking care of patients with similar diagnosis at other urban academic medical institutions.

Identifying Value Factors in Institutional Leaders’ Perspectives on Investing in Health Professions Educators

Investing in educators, educational innovation, and scholarship is essential for excellence in health professions education and health care. Funds for education innovations and educator development remain at significant risk because they virtually never generate offsetting revenue. A broader shared framework is needed to determine the value of such investments. To explore the value factors using the value measurement methodology domains (individual, financial, operational, social or societal, strategic or political) that health professions leaders placed on educator investment programs, including intramural grants and endowed chairs. This qualitative study used semi-structured interviews with participants from an urban academic health professions institution and its affiliated systems that were conducted between June and September 2019 and were audio recorded and transcribed. Thematic analysis was used to identify themes with a constructivist orientation. Participants included 31 leaders at multiple levels of the organization (eg, deans, department chairs, and health system leaders) and with a range of experience. Individuals who did not respond initially were followed up with until a sufficient representation of leader roles was achieved. Outcomes include value factors defined by the leaders for educator investment programs across the 5 value measurement methodology domains: individual, financial, operational, social or societal, and strategic or political. This study included 29 leaders (5 [17%] campus or university leaders; 3 [10%] health systems leaders; 6 [21%] health professions school leaders; 15 [52%] department leaders). They identified value factors across the 5 value measurement methods domains. Individual factors emphasized the impact on faculty career, stature, and personal and professional development. Financial factors included tangible support, the ability to attract additional resources, and the importance of these investments as a monetary input rather than output. Operational factors identified educational programs and faculty recruitment or retention. Social and societal factors showcased scholarship and dissemination benefits to the external community beyond the organization and to the internal community of faculty, learners, and patients. Strategic and political factors highlighted impact on culture and symbolism, innovation, and organizational success. These findings suggest that health sciences and health system leaders find value in funding educator investment programs in multiple domains beyond direct financial return on investment. These value factors can inform program design and evaluation, effective feedback to leaders, and advocacy for future investments. This approach can be used by other institutions to identify context-specific value factors.

Shared governance council to engage advanced practice registered nurses in a hospital setting.

Health care organizations use advanced practice registered nurses (APRNs) to expand patient access and support high-quality care. However, turnover, often exacerbated by inadequate engagement, has steep financial and experiential costs. The project site, a large urban academic institution with quaternary care capabilities, employs more than 300 APRNs to provide patient care. Due to variations in hiring entity, leadership structure, and organizational visibility, efforts to maintain APRN engagement were complex. In addition, inconsistencies in standardization of clinical, credentialing, and privileging procedures created organizational risk. Quality improvement principles informed the implementation of a shared governance council for APRNs that included nurse practitioners and certified registered nurse anesthetists. Data were collected pre and postintervention using validated engagement questions. Implementation of a shared governance council to support the organizational engagement of APRNs through decisional involvement in professional practice issues. Analysis included the percentage of change in aggregate scores and the Wilcoxon rank-sum test to obtain p values of the 2 independent samples. There was an 8.9% increase in aggregate postintervention scores and statistical improvement in measures of quality improvement involvement. Participation in the shared governance council increased APRN engagement through enhanced opportunities to communicate professional and clinical practice issues, decisional involvement, and collaboration. Statistically significant improvements in quality improvement involvement values potentially affirm the council's role in facilitating work environment improvements. Potential long-term gains include improved job satisfaction, retention, and organizational cost savings.

Association of Community-Level Socioeconomic Distress with Nutritional Status in People with Sickle Cell Anemia

Introduction: Sickle cell anemia (SCA) is characterized by a myriad of acute and chronic complications. These complications negatively impact the ability to achieve educational and occupational goals making this group a particularly vulnerable population to socioeconomic challenges (PMID 30540112). Furthermore, most patients with SCA in the U.S. are Black and are disproportionately affected by socioeconomic inequity due to the historical effects of systemic racism (PMCID: PMC4817358). In the general population, indices of socioeconomic distress are associated with poor nutrition (PMID 25573510). Patients with SCA also experience a high frequency of food insecurity (PMID 34811867). The association of community-level socioeconomic distress with nutritional status in people with SCA is unknown. Methods: We conducted a cross-sectional study to describe the burden of community-level socioeconomic distress and its impact on nutritional status in an SCA cohort (n=332) treated at an urban academic institution. The distressed community index (DCI), a composite of socioeconomic indicators (including no high school diploma, housing vacancy rate, adults not working, poverty rate, median income ratio, and changes in employment and establishments) that estimate the economic well-being of a community, was determined for each individual patient's residential address using 2014-2018 U.S. Census Bureau's American Community Survey and the Business Patterns database. DCI score ranges from 0-100 with a higher score indicating a more distressed community. The association of DCI with measures of nutritional status (serum albumin, body mass index [BMI], vitamin D 25-OH) and hemoglobin concentration were determined using linear regression. The analyses were adjusted for age, sex, and hydroxyurea use. The beta coefficients provided are based on increments of 10 for DCI. Median and interquartile ranges (IQR) are provided. Results: The median age of the cohort was 31 years (IQR, 24-41 years), 55% were female, 53% were on hydroxyurea therapy, and the median BMI was 23 kg/m2 (IQR, 21-26 kg/m2). The median DCI in this cohort was 87 (IQR, 61-96) with 61% of SCA patients living in a distressed tier (DCI≥ 80) and only 5% living in a prosperous tier (DCI< 20). A higher DCI, reflecting an increase in socioeconomic distress, was associated with a trend for a lower odds ratio (OR) of being on hydroxyurea therapy (OR 0.93; 95% CI 0.86-1.0). An increasing DCI was significantly associated with lower serum albumin (β= -0.02; P=0.016), BMI (β= -0.01; P=0.045), and vitamin D 25-OH levels (β= -0.7; P=0.001), adjusting for age, sex, and hydroxyurea use (Figure). Furthermore, SCA patients living in a more distressed community had a trend for lower hemoglobin concentrations (β= -0.05; P=0.077) with similar adjustments. Discussion: In conclusion, we demonstrate that a high proportion of patients with SCA treated at an urban academic institution live in distressed socioeconomic communities. Higher distressed community indices are associated with lower utilization of hydroxyurea and lower measures of nutritional status. Future studies investigating the effects of socioeconomic distress on access to outpatient care and healthy foods may guide public health strategies to improve health disparities in the SCA population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The Effect of Preoperative Benzodiazepine Usage on Postoperative Opioid Consumption After Hand Surgery: A Multicenter Analysis.

Background Prescription rates of opioids and benzodiazepines have steadily increased in the last decadewith the percentage of prescription opioid overdose deaths involving benzodiazepines more than doubling during that time. Orthopaedic surgery is one of the highest-volume opioid prescribing medical specialties, but the effects of benzodiazepine use on orthopaedic surgery patient outcomes are not well understood. The purpose of the study was to utilize the state Prescription Drug Monitoring Program (PDMP) database to investigate if perioperative benzodiazepine use predisposes patients to prolonged opioid use following hand and upper extremity orthopaedic surgery. Methods This study was retrospective and conducted at three urban academic institutions. All patients who underwent carpal tunnel release, thumb basal joint arthroplasty, and distal radius fracture open reduction internal fixation performed by 14 board-certified, fellowship-trained orthopaedic hand and upper extremity surgeons between April 2018 and August 2019, were collected via a database query. All opioid and benzodiazepine prescriptions were collected from three months preoperatively to six months postoperatively. Results In this study, 634 patients met the inclusion criteria presented to one of the three institutions during the 18-month study period. Patients consisted of 276 carpal tunnel releases, 217 distal radius fracture open reduction internal fixations, and 141 thumb basal joint arthroplasties. Benzodiazepine users were 14.6% more likely to fill an additional opioid prescription (p<0.005) and were 10.8% more likely to experience prolonged three to six-month postoperative opioid use (p<0.005). Conclusion This study found that patients who use benzodiazepines are at a higher risk of filling additional opioid prescriptions and prolonged opioid use following hand and upper extremity surgery. Prescribers should take this into account when prescribing opioids after upper extremity orthopaedic surgery.

Factors Influencing Patient Preference for Anesthesia in Ambulatory Hand Surgery.

The purpose of this study was to identify factors that influence preoperative patient preferences toward anesthesia in patients in a hand and upper extremity clinic. A survey was administered to consecutive patients in a hand and upper extremity orthopedic clinic at an urban tertiary academic institution. The survey addressed presenting clinical complaint, anesthesia preference for minor soft tissue hand and wrist procedures, factors influencing anesthesia preference, and patient history of anesthesia and surgical treatment. The primary outcome measure was anesthesia preference: local-only or local with sedation. Surveys were completed by 219 patients over a 1-month period with a mean patient age of 55 years. Most patients presented with a hand/wrist complaint (56%). One hundred fifty-two patients (71%) preferred local anesthesia with sedation and 61 patients (29%) preferred local-only anesthesia. Patients who preferred local-only anesthesia reported being more likely to be influenced by surgeon preference and cost, and also were more likely to have had prior experience with local-only anesthesia. In contrast, patients who preferred local anesthesia with sedation were more likely to be concerned about pain or were nervous about surgery. Prior surgical experience did not influence preference for anesthesia. Patient preferences for local-only anesthesia versus local anesthesia with sedation for ambulatory hand surgery are mixed, with most patients preferring sedation. Understanding patient preferences for anesthesia can better inform preoperative discussions and shared decision-making in anesthesia choice.

Increasing statin prescription rates to prevent cardiovascular disease among high-risk populations: a quality improvement intervention centred on a novel interactive tool

Statins are indicated for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD). Our previous study of 1042 consecutive patient encounters at our large urban academic institution found that one...

P-020: IMPLICATIONS OF SOCIOECONOMIC DISTRESS ON NUTRITIONAL STATUS AND KIDNEY FUNCTION IN PEOPLE WITH SICKLE CELL ANEMIA

Purpose: Sickle cell anemia (SCA) is characterized by a myriad of acute and chronic complications. These complications negatively impact the ability to achieve educational and occupational goals making this group a particularly vulnerable population to socioeconomic challenges (PMID 30540112). In the general population, indices of socioeconomic distress are associated with poor nutrition and kidney disease risk (PMID 25573510). The association of socioeconomic distress with nutritional status and kidney function in people with SCA is unknown. Materials and methods: We conducted a cross-sectional study to describe the burden of socioeconomic distress and its impact on nutritional status and kidney function in an SCA cohort (n=332) treated at an urban academic institution. The distressed community index (DCI), a composite of socioeconomic indicators that estimate the economic well-being of a community, was determined for each individual using the following website: https://eig.org/dci/interactive-map. A higher DCI score indicates a more distressed community. The associations of DCI with measures of nutritional status (serum albumin, body mass index [BMI], vitamin D 25-OH) and kidney function (estimated glomerular filtration rate [eGFR]; albuminuria; serum bicarbonate, potassium, and erythropoietin levels), were determined using linear or logistic regression. The analyses were adjusted for age, sex, and hydroxyurea use for nutritional status as well as for APOL1 G1 and G2 risk status for kidney function. The beta coefficients provided are based on increments of 10 for DCI. Median and interquartile ranges (IQR) are provided. Results: The median age of the cohort was 31 years (IQR, 24 – 41 years), 55% were female, and 53% were on hydroxyurea therapy. The median DCI in this cohort was 87 (IQR, 61 – 96) with 61% of SCA patients living in a distressed tier (DCI≥ 80) and only 5% living in a prosperous tier (DCI< 20). The DCI tiers for SCA patients trended towards more socioeconomically distressed communities compared to the general African American population (P=0.1) (Figure 1A). A higher DCI, reflecting an increase in socioeconomic distress, was associated with a trend for a lower odds ratio (OR) of being on hydroxyurea therapy (OR 0.93, 95% CI: 0.86 – 1.01; P=0.08). An increasing DCI was significantly associated with lower serum albumin (β= -0.02; P=0.016) (Figure 1B), BMI (β= -0.01; P=0.045), and vitamin D 25-OH levels (β= -0.7; P=0.001) (Figure 1C). A higher DCI was associated with a trend for a lower eGFR (β= -0.6; P=0.09) (Figure 1D) while no association was observed with urine albumin concentration (P=0.8). Lower serum bicarbonate (β= -0.1; P=0.02) and lower erythropoietin (β= -0.9; P=0.1) levels, but not serum potassium concentration (P=0.9), were also associated with higher DCI. Conclusion: In conclusion, we demonstrate that a high proportion of patients with SCA treated at an urban academic institution live in distressed socioeconomic communities. Furthermore, higher distressed community indices are associated with lower measures of nutritional status and with some markers of impaired kidney function. Future studies investigating the effects of socioeconomic distress on access to healthy foods and kidney disease risk may guide public health strategies to improve health disparities in the SCA population.Figure 1. The authors do not declare any conflict of interest

Measuring health disparity index in gynecologic oncology (281)

<b>Objectives:</b> A health disparity index (HDI) can be used to regularly assess quality metrics by race and ethnicity. Our objective was to describe the implementation of the HDI for gynecology oncology patients at a tertiary-care academic center. <b>Methods:</b> We systematically collected reportable quality events for gynecologic oncologic patients at a single academic institution over a one-year period, July 2020 - June 2021, who were presented at the department's bimonthly morbidity and mortality quality forum. Reportable events were mainly postoperative complications and were predefined as death within 30 days, transfusion of greater than four units of blood products, hospital stay greater than 15 days, unplanned transfer to the intensive care unit, unanticipated return to the operating room, re-admission within 30 days, venous thromboembolic event, operative injury, surgical site infection, and estimated blood loss greater than 750 mL for benign cases. The calculation below was used to compare events in Black patients compared to White patients. The race was self-reported and extracted from the electronic medical record. For the purposes of this calculation, reportable events were considered binary (i.e., patients either had or did not have a reportable event). A Chi-square test was used to compare the two populations. An HDI of 1 describes equal morbidity in White and Black patients, HDI <1 greater morbidity in White patients, and HDI >1 greater morbidity in Black patients. <b>Results:</b> A total of 458 patients underwent surgery with the gynecologic oncology service from July 2020 to June 2021 at The Hospital of the University of Pennsylvania. Sixty-two percent (<i>n</i>=284) identified as White, 29.7% (<i>n</i>=136) identified as Black, and 8.3% (<i>n</i>=38) identified as a race or ethnicity that was not White or Black. There were 73 reported events captured in the safety net reporting application. Of those 73 events, 33% (<i>n</i>=24) were for Black patients, 60% (<i>n</i>=44) were white patients, while the remaining 7% (<i>n</i>=5) were for all remaining patients. The proportion of Black patients with a reportable event was 17.6% (24/136), with a 95% CI of 11.6-25.1. The proportion of White patients with a reportable event was 15.5% (44/284), with a 95% CI of 11.5-20.2. The HDI presented at individual quality forums ranged from 0.50 to 5.1 over a 12-month period. The mean HDI is 1.14 with a 95% CI of 0.72-1.79 (p=0.57). <b>Conclusions:</b> From July 2020 to June 2021, the HDI was greater than 1 for our gynecologic oncology patients, indicating that a disparity in surgical and medical outcomes was present at a large urban academic institution. The wide range, as well as statistically non-significant p-value, is likely attributable to the small cohort. Using this HDI, our department is undertaking innovative quality improvement efforts to close the health disparity gap seen amongst gynecologic oncology patients.

The Effect of Femoral Head Size on Groin Pain in Total Hip Arthroplasty.

Although increased femoral head size reduces the risk of instability in total hip arthroplasty (THA), it may lead to iliopsoas irritation and increased anterior groin pain. The purpose of this study is to compare outcomes between non-modular dual-mobility (NDM) implants and small (≤32 mm) and large (≥36 mm) fixed-bearing (FB) constructs. A retrospective review of all primary total hip arthroplasties from 2011 to 2021 was conducted at a single, urban academic institution. Patients were separated into 3 cohorts: NDM implant ≤32 mm and FB implant ≥36 mm. Demographics and outcomes such as length of stay, dislocation, and anterior groin pain were assessed. Patients were deemed as having groin pain if they received an iliopsoas injection or had extended physical therapy ordered beyond 3 months postoperatively. There were 178 NDM implants, 936 ≤32-mm FB, and 2,454 ≥36-mm FB implants included. Length of stay significantly differed between the groups (48.4±43.3 vs 63.2±40.6 vs 57.2±38.1hours; P= .001). Although not statistically significant, the ≥36-mm FB cohort had the highest rate of dislocations (0.6% vs 0.7% vs 0.9%; P= .84). Although no patients with an NDM implant received an iliopsoas injection, 9 patients (0.9%) with a ≤32-mm FB implant and 9 patients (0.4%) with a ≥36-mm implant received an injection (P= .06). However, 18 (10.1%) patients with an NDM implant, 304 (32.5%) patients with a ≤32-mm FB implant, and 355 (14.5%) patients with a ≥36-mm FB implant received extended physical therapy 3 months after surgery (P < .001). NDM implants, as well as FB implants with both small and large head sizes are effective at preventing dislocation. NDM implants did not result in an increase in anterior groin pain compared to ≤32-mm and ≥36-mm FB constructs. Retrospective cohort study.

Enhanced Recovery after Surgery Protocol to Improve Racial and Ethnic Disparities in Postcesarean Pain Management.

The objective of this study was to assess the efficacy of an enhanced recovery after surgery (ERAS) protocol and determine its effect on racial/ethnic disparities in postcesarean pain management. We performed an institutional review board-approved retrospective cohort study of scheduled cesarean deliveries before and after ERAS implementation at a single urban academic institution. Pre-ERAS, all analgesic medications were given postoperatively on patient request. The ERAS protocol included preoperative acetaminophen and celecoxib. Postoperatively, patients received scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Oral oxycodone was available as needed, and opioid patient-controlled analgesia was eliminated from the standard order set. The primary outcome was total opioid use in the first 48 hours after cesarean, pre- and post-ERAS, reported in total milliequivalents of intravenous morphine (MME). A secondary analysis of opioid use and pain scores by racial groups was also performed. Chi-square, independent t-tests, analysis of variance, Mann-Whitney U, and Kruskal-Wallis tests were used depending on variable and data normality. Pre-ERAS and post-ERAS groups included 100 women each. Post-ERAS, total opioid use in 48 hours was less (40.8 vs. 8.6 MME, p < 0.001) and visual analog scale (VAS) pain scores were lower on postoperative day 1 (POD1) and 2 (POD2) (POD1 maximum at rest: 6.7 vs. 5.3, p < 0.001). Pre-ERAS pain scores differed by race with non-Hispanic Black (NHB) patients reporting the highest mean and max VAS pain scores POD1 and POD2 (POD1, maximum VAS at rest: NHB-7.4, non-Hispanic White-6.6, Hispanic-5.8, Asian-4.4, p = 0.006). Post-ERAS, there were no differences in postoperative pain scores between groups with movement on POD1 and POD2. A standardized ERAS protocol for postcesarean pain decreases opioid use and may improve some racial disparities in postcesarean pain control. · ERAS protocols improve postoperative pain control and lower postoperative opioid use.. · Studies show that there are racial and ethnic disparities in postpartum pain control.. · Protocols standardize care and may decrease the effects of provider implicit bias..

Incidence of post-stroke depression symptoms and potential risk factors in adults with aphasia in a comprehensive stroke center

ABSTRACT Introduction Depression may be a frequent sequela after stroke, however, its incidence has rarely been reported. The likelihood of post-stroke depression (PSD) may relate to individual factors including the presence of aphasia, which also complicates PSD diagnosis. The current study’s purpose was to investigate the incidence of PSD symptoms in adults with aphasia, compare it to the incidence of PSD symptoms in adults without aphasia, and to identify potential risk factors for developing PSD in adults with aphasia. Method Incidence proportions and relative risk were calculated using data compiled from 970 patient records at an urban tertiary care academic institution and comprehensive stroke center throughout the year of 2019. Focusing exclusively on adults with aphasia, the selected variables of age, gender, race, and aphasia severity were used to conduct logistic regression analyses to explore potential risk factors contributing to the development of PSD. Results Adults with aphasia were 7.408 times more likely to exhibit PSD symptoms than adults without aphasia. Logistic regression controlling for the presence of aphasia showed a significant relationship between aphasia severity and post-stroke depression symptoms. Adults with aphasia were 2.06 times more likely to experience post-stroke depression symptoms with every 1-point increase in aphasia severity. Conclusions These findings align with earlier evidence identifying aphasia as a risk factor for experiencing PSD symptoms and also suggest aphasia severity is proportionate to the risk. This highlights the need for early identification of PSD symptoms in persons with aphasia in order to provide timely interventions.

Prevalence of Postpartum Depression Following the COVID-19 Pandemic at an Urban Academic Institution [A235

INTRODUCTION: Postpartum depression (PPD) is a complication of pregnancy commonly occurring within the first month of delivery. Numerous risk factors are associated with PPD, including financial stressors, inadequate emotional support, and perceived social isolation. This study evaluated the impact of the implemented social restrictions to mitigate the spread of the COVID-19 virus on the overall prevalence of PPD at an urban academic center. METHODS: Following institutional review board approval, a retrospective cohort study was performed of 1,097 subjects between 1 and 8 weeks postpartum. Group 1, the control group, included 420 women with routine PPD screening prior to the COVID-19 pandemic (April 1–December 31, 2019). Group 2, our case group, included 677 women with routine PPD screening during the pandemic (April 1–December 31, 2020). Both groups completed the Edinburgh Postnatal Depression Scale (EPDS), and the prevalence of PPD (defined as having an EPDS score greater than 11) was determined. Postpartum patients following fetal demise were excluded. RESULTS: The prevalence of PPD was higher in postpartum women before the COVID-19 pandemic (13.10%) when compared to postpartum women screened during the pandemic (10.78%). This increased prevalence, however, was not found to be statistically significant (P=.2474). CONCLUSION: Our study revealed no statistically significant difference in the prevalence of PPD before or during the COVID-19 pandemic. Nevertheless, the downward trend of PPD during the pandemic may be due to quarantine recommendations allowing families/spouses to work from home. The association of PPD and specific social support systems should be evaluated further.

No Thromboembolic Complications After Facial Feminization Surgery in Transgender Patients Utilizing Estrogen Therapy: A Retrospective Cohort Study.

Estrogen therapy is associated with an increased risk of venous thromboembolism (VTE). A large proportion of transfeminine patients use estrogen therapy before undergoing gender-affirming surgery. Many surgeons implement the discontinuation of hormone therapy before surgery. This study sought to evaluate the perioperative risk of VTE in transfeminine patients undergoing the procedure of facial feminization. Retrospective chart reviews were performed of all patients who underwent facial feminization by a single surgeon at an urban academic institution from 2014 to 2020. Patient characteristics including comorbidities, Caprini score, VTE chemoprophylaxis, and perioperative hormone therapy management were reviewed. The incidences of VTE during perioperative hospital stay and within 1 week and 6 months after the surgical procedure were examined. There were 296 facial feminization procedures performed on 282 distinct patients who met criteria for inclusion in the study. Hormone therapy was prescribed to 83.6% of patients, 69.5% of whom reported that they held these medications before the procedure. Of those holding, 84.1% of patients reported they discontinued these medications between 2 and 4 weeks. No patients received VTE chemoprophylaxis. There were 0 VTE incidents during the patients' perioperative period up to 6 months postprocedure. Our findings support that transfeminine patients who use estrogen hormone therapy are at a minimal risk to experience VTE when undergoing facial feminization procedures. Future directions include evaluating the psychologic effect of discontinuing hormone therapy to help guide perioperative decision making.

191 Clinical and Economic Outcomes of Patients Undergoing Surgical Intervention for Trigeminal Neuralgia: Analysis From a National Database

INTRODUCTION: The management of trigeminal neuralgia (TN) has evolved significantly in the past century. In the current manuscript, we compare clinical and economic outcomes of patients undergoing surgical intervention for TN between microvascular decompression (MVD), percutaneous procedures and stereotactic radiosurgery (SRS) using a national database. METHODS: The national inpatient sample (NIS) was queried for cases undergoing a surgical intervention for TN between 2002-2015 3rd quarter using the International Classification of Disease 9th Revision Clinical Modification (ICD-9-CM) and procedure codes (ICD-9-PCS). Outcomes assessed included length of stay (LOS), discharge disposition and cost. RESULTS: A total of 8,317 patients undergoing a surgical intervention for TN were identified between 2002 and 2015 3rd quarter, of which 7,202 (86.6%) underwent MVD, 548 (6.6%) underwent percutaneous procedures and 567 (6.8%) underwent SRS. Patients undergoing percutaneous and SRS procedures were more likely to be older compared to those undergoing MVD (&gt;65: 58.1% and 72.1% vs 32.2%, respectively; p &lt; 0.001). MVD was significantly more likely to be performed in an urban academic institution compared to percutaneous procedures and SRS (84.8% vs 75.1% and 75.8%; p &lt; 0.001). Patients undergoing SRS had the lowest LOS (1.34 days vs 3.2 days and 3.5 days; p &lt; 0.001) and lowest odds for a prolonged LOS (OR = 0.29; CI: 0.18-0.46; p &lt; 0.001) and non-routine discharge (OR = 0.44; CI: 0.28-0.71; p &lt; 0.001). Percutaneous procedures had the highest odds for a prolonged LOS (OR = 2.07; CI: 1.65-2.61; p &lt; 0.001). The total charges billed by the hospital were highest for patients undergoing MVD ($50,432.30) followed by those undergoing SRS ($38,450.90) and percutaneous procedures ($18,655.10) (p &lt; 0.001). The total reimbursed cost was highest for SRS ($18,265.70) followed by MVD ($17,590.20) and percutaneous procedures ($8,183.30). CONCLUSION: In the current era of value-based care, these analyses are important in helping physicians, hospitals and other stakeholders devise appropriate policies to ensure optimal patient outcomes, as well as optimal reimbursements.

Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study.

ObjectiveTo investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED).Materials and MethodsThis retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate.ResultsAccording to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4–27.5 hours) to 11.6 hours (6.6–21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5–30.1 hours) to 9.6 hours (5.7–19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6–16.5 hours) to 6.7 hours (4.9–11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001).ConclusionQIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.

Improving adherence to cholesterol lowering guidelines through an interactive digital tool

Abstract Background Statins are the cornerstone of primary and secondary prevention of atheroscleoric cardiovascular disease (ASCVD). Our previous retrospective analysis of 1042 consecutive patient encounters at a large urban academic institution found that one in five patients were not prescribed an appropriate statin therapy. These patients tended to be younger, of Black race, and met statin-eligibility solely via a 10-year ASCVD risk score ≥7.5%. Only one-third of patients had follow-up cholesterol levels ordered to monitor treatment efficacy. Purpose To improve adherence to cholesterol guidelines at our academic institution. Methods We implemented multiple interventions over a four-month period to support clinical decision making of guideline directed statin therapy: a) development of an online interactive tool, b) physician education on updated cholesterol guidelines and utilization of the tool, c) display of guideline summary in the workspace, and d) a documentation reminder in the electronic health record. We randomly selected encounter dates, from which 622 consecutive patient visits were analyzed. The primary outcome measures were: prescription rates of statins, documentation of a 10-year ASCVD risk score, and follow-up cholesterol levels ordered to monitor treatment efficacy. Results Out of the 622 patients, 232 met statin indication. In this post-intervention group, statin prescriptions rates improved when compared to the pre-intervention group (90.5% vs 82.3%, p=0.006). Among the patients who met statin indication solely via a 10-year ASCVD risk score ≥7.5%, there was an increase in documentation of the calculated 10-year ASCVD risk score (72.3% vs 57.8%; p=0.039) and in statin prescription rate (90.8% vs 67.6%; p&amp;lt;0.001). In addition, there was an increase in follow-up cholesterol levels ordered in all patients included in our study who met statin indication (64.1% vs 33.3%; p&amp;lt;0.001). Conclusion Our study showed higher rates of statin prescription, 10-year ASCVD risk score documentation, and treatment monitoring after multiple interventions, including an easily accessible online interactive tool, at a large urban academic institution. Funding Acknowledgement Type of funding sources: None. Statin Prescription Rates

Abstract 11345: Incidence, Characteristics, and Outcomes of Patients Presenting to an Urban Academic Institution with ST-Segment Elevation Myocardial Infarction During the COVID-19 Pandemic

Introduction: ST-segment elevation myocardial infarction (STEMI) is an emergency presentation of an acutely occluded coronary artery. Following the announcement of the COVID-19 pandemic (March 11, 2020), a global decrease in STEMI incidence has been observed. Incidence, characteristics, and outcomes for STEMI activation patients were investigated in the 5 years prior (“reference period”) to and 1 year into the pandemic (“pandemic period”). We assessed the hypothesis that pandemic period STEMI activations will have more severe infarction (elevated troponin I), a higher percentage of true STEMI, and worse outcomes (higher case fatality rate). Methods: STEMI activation incidence was obtained from an institutional database (reference period n = 430; pandemic period n = 31). Patient characteristics and outcomes were obtained retrospectively from electronic health records (EHRs). True STEMI was adjudicated based on chest pain, EKG, troponins, and angiogram. Results: Monthly STEMI activations declined significantly in the first year of the pandemic (2.50 ± .68 vs. 7.17 ± .41, P = &lt;.001). No significant difference in demographic characteristics (age, BMI, and male-to-female ratio) were observed. True STEMI percentage was higher during the pandemic (80.65% vs. 70.93%), but not statistically significant. Peak troponin levels for true STEMI were significantly higher during the pandemic (98.83 ± 25.82 vs. 51.44 ± 4.11, P = .003). There was no significant difference in 30-day and 90-day case fatality rates. Conclusions: STEMI activation incidence declined significantly during the pandemic; interestingly, the proportion of these which were true STEMIs remained consistent. True STEMIs during the pandemic had higher troponin levels suggesting larger infarct, but there was no significant difference in case fatality. In conclusion, fewer patients presented with STEMI while case fatality remained unchanged despite more severe infarct occurrence during the pandemic.

Radiation Oncology Alternative Payment Model and Large Urban Academic Centers: Future Implications for Patients and Providers.

The radiation oncology alternative payment model (RO-APM) was developed by the Center for Medicare and Medicaid Innovation, a part of the Centers for Medicare & Medicaid Services, as a vehicle to optimize value for patients undergoing radiation therapy. By shifting reimbursement away from fee-for-service and toward a prospective bundled payment system, the RO-APM is intended to bend the cost curve in radiation oncology while preserving or even enhancing outcomes. As with prior large-scale policy initiatives, the nature and magnitude of the RO-APM's impact on care delivery will vary substantially depending on a host of local factors, including practice setting. Urban academic centers play a key role in radiation oncology by spearheading innovation, managing the most complicated cases, training the next generation of radiation oncologists, and often caring for vulnerable patient populations. Thus, to protect patients' access to this high-quality cancer care, it will be crucial to characterize the RO-APM's projected impact on large urban academic institutions before its implementation, including possible unintended adverse consequences. Here, we provide an overview of this seismic change in radiation oncology reimbursement and discuss its unique potential implications for large urban academic institutions as a means to facilitate necessary preparations and inform future revisions to the model.

Fibroids as a Risk Factor for Deep Vein Thrombosis (DVT) at an Urban Academic Institution: A Retrospective Observational Study

<h3>Study Objective</h3> To assess if and how fibroids increase the risk of developing a DVT, and review how these patients have been managed. <h3>Design</h3> This retrospective observational study reviews the characteristics of fibroids in patients who have been diagnosed with a DVT. <h3>Setting</h3> Urban academic tertiary-care hospital, single institution. <h3>Patients or Participants</h3> Women ages 18 to 65 years old with a diagnosis of a fibroid uterus who had a thrombotic event from January 1, 2012, to December 31, 2019, were reviewed. ICD-10 codes were used to obtain charts of a total of 1293 patients. Of these, 221 met inclusion criteria and 73 underwent full chart review. Their average BMI was 34.5 and average hemoglobin was 10.2. <h3>Interventions</h3> A retrospective observational chart review was completed to assess how patients with a fibroid uterus who had a thrombotic event were managed and the characteristics of these fibroid uteri. <h3>Measurements and Main Results</h3> 100% of the patients (n=73) were diagnosed with a fibroid uterus and lower extremity DVT and/or pulmonary embolism (PE). 66% (n=48) of these thrombotic events were unprovoked. Of those that were provoked, 32% (n=8) were postoperative after a hysterectomy for symptomatic uterine fibroids. Of those patients diagnosed with a thrombotic event subsequently needing surgery for their fibroids, only 24% (n=4) were able to complete their surgery within the first 3 months of the thrombotic event. Characteristics of fibroids in patients with a thrombotic event were as follows: the mean size of the largest fibroid was 6.3cm; the mean uterine volume was 575cc with 64% of the uteri ranging from 100-700cc; 80% had 5 or fewer fibroids with 16% only having one fibroid. <h3>Conclusion</h3> Fibroid uteri may be an independent risk factor for developing a DVT in women ages 18 to 65 years old. These patients should be risk-stratified and appropriate chemoprophylaxis should be considered in an attempt to prevent thrombotic events.