Patient Healthcare Utilization Research Articles

Effectiveness of the transitional care model in total knee arthroplasty patients: A randomized controlled trial.

This study has aimed to assess the effectiveness of the transitional care model (TCM) on functional status, perceived self-efficacy and healthcare utilization in patients undergoing total knee arthroplasty (TKA). This randomized controlled study was conducted between February and November 2021 in a public hospital. The study randomly assigned patients to either a 6-week 'TCM' program or usual care. The sample size was n = 70, with each group comprising 35 individuals. Patient outcomes, including self-efficacy, functional status and healthcare service readmission rates, were monitored for TKA patients. Nursing care based on the 'TCM' was found to enhance functional status and increase the level of self-efficacy among TKA patients, leading to a decrease in healthcare service readmissions. The study recommends preparing patients and their families for the preoperative and postoperative processes. It emphasizes the importance of providing necessary training and consultancy services under the leadership of orthopaedic nurses responsible for TKA patient care, guided by the principles of TCM.

Outcomes After a Statewide Policy to Improve Evidence-Based Treatment of Back Pain Among Medicaid Enrollees in Oregon.

A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies. To examine the effect of the policy on prescribing, health outcomes, and health service utilization. Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy's association with selected outcomes using interrupted time series models. Adult Medicaid patients with back pain enrolled between 2014 and 2018. The Oregon Medicaid back pain policy. Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization. The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (- 2.68 percentage points [95% CI - 3.14, - 2.23] level, - 1.01pp [95% CI - 1.1, - 0.92] slope), days of short-acting opioid use (- 0.4days [95% CI - 0.53, - 0.26] slope), receipt of more than 7days of short-acting opioids (- 2.36pp [95% CI - 2.76, - 1.95] level, - 0.91pp [95% CI - 1, - 0.83] slope), chronic opioid use (- 1.27pp [95% CI - 1.59, - 0.94] level, - 0.46 [95% CI - 0.53, - 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm. A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.

Association between acute peripancreatic fluid collections and early readmission in acute pancreatitis: A propensity-matched analysis.

Patients with acute pancreatitis (AP) frequently experience hospital readmissions, posing a significant burden to healthcare systems. Acute peripancreatic fluid collection (APFC) may negatively impact the clinical course of AP. It could worsen symptoms and potentially lead to additional complications. However, clinical evidence regarding the specific association between APFC and early readmission in AP remains scarce. Understanding the link between APFC and readmission may help improve clinical care for AP patients and reduce healthcare costs. To evaluate the association between APFC and 30-day readmission in patients with AP. This retrospective cohort study is based on the Nationwide Readmission Database for 2016-2019. Patients with a primary diagnosis of AP were identified. Participants were categorized into those with and without APFC. A 1:1 propensity score matching for age, gender, and Elixhauser comorbidities was performed. The primary outcome was early readmission rates. Secondary outcomes included the incidence of inpatient complications and healthcare utilization. Unadjusted analyses used Mann-Whitney U and χ 2 tests, while Cox regression models assessed 30-day readmission risks and reported them as adjusted hazard ratios (aHR). Kaplan-Meier curves and log-rank tests verified readmission risks. A total of 673059 patients with the principal diagnosis of AP were included. Of these, 5.1% had APFC on initial admission. After propensity score matching, each cohort consisted of 33914 patients. Those with APFC showed a higher incidence of inpatient complications, including septic shock (3.1% vs 1.3%, P < 0.001), portal venous thrombosis (4.4% vs 0.8%, P < 0.001), and mechanical ventilation (1.8% vs 0.9%, P < 0.001). The length of stay (LOS) was longer for APFC patients [4 (3-7) vs 3 (2-5) days, P < 0.001], as were hospital charges ($29451 vs $24418, P < 0.001). For 30-day readmissions, APFC patients had a higher rate (15.7% vs 6.5%, P < 0.001) and a longer median readmission LOS (4 vs 3 days, P < 0.001). The APFC group also had higher readmission charges ($28282 vs $22865, P < 0.001). The presence of APFC increased the risk of readmission twofold (aHR 2.52, 95% confidence interval: 2.40-2.65, P < 0.001). The independent risk factors for 30-day readmission included female gender, Elixhauser Comorbidity Index ≥ 3, chronic pulmonary diseases, chronic renal disease, protein-calorie malnutrition, substance use disorder, depression, portal and splenic venous thrombosis, and certain endoscopic procedures. Developing APFC during index hospitalization for AP is linked to higher readmission rates, more inpatient complications, longer LOS, and increased healthcare costs. Knowing predictors of readmission can help target high-risk patients, reducing healthcare burdens.

Patients With Spina Bifida Have Longer Length of Hospital Stay: Statewide Health Care Utilization in California From 1995 to 2017.

Our goal was to better understand the health care utilization of patients with spina bifida (SB) by evaluating length of hospital stay (LOS) as well as identifying what characteristics within the SB population are contributing to shorter or longer LOS. By querying the Department of Health Care Access and Information database of all encounters at California-licensed hospitals from January 1995 through December 2017, this study analyzed LOS as a measure of health care utilization. Patients with SB were identified using the International Classification of Diseases-9 and -10 coding system, and the data collected for both SB and control cohorts were compared using linear and logistic regression models. Patients with SB spent a mean LOS of 7.3 days compared to 4.7 days among the control cohort (P < .001). In multivariable analysis, SB was found to be an independent predictor of longer LOS. Within the SB encounters, increasing comorbidities and nonprivate insurance were associated with longer LOS, while being female and Hispanic were associated with a shorter LOS. SB is an independent predictor of longer LOS when compared to the control cohort. These findings highlight the importance of understanding the preventive health care access and needs of the vulnerable SB population to decrease hospital utilization rates.

An Evaluation of the Demographics, Characteristics and Healthcare Utilisation of People with Asthma Referred to an Ambulatory Respiratory Hub

Background Asthma is the most treated condition in the Ulster Hospital Ambulatory Respiratory Hub (ARH). This multidisciplinary rapid assessment and treatment centre reviews respiratory patients to prevent hospital admission. This service evaluation (SE) may identify improvements for the service and better outcomes for asthma patients. Aims The demographics, clinical characteristics including biomarker profile and co-morbidities, alongside subsequent healthcare utilisation of patients with asthma were explored. Method Retrospective review of electronic healthcare records identified 151 patients with asthma attending the ARH between 1st July 2019 and 31st Dec 2019. Baseline demographics, clinical characteristics, comorbidities and asthma biomarkers were extracted. Patients were characterised according to their T2-biomarker expression and comparisons made. Healthcare utilisation was assessed by collecting data regarding hospital admissions, emergency department attendances and GP out of hours visits 6 months before and after attending the service. Results Most patients with asthma were female (73.5%), T2- biomarker low (74.2%) and had a high prevalence of obesity (49%). Prevalent comorbidities included rhinosinusitis, gastro-oesophageal reflux disease, depression and anxiety. Investigations included spirometry, chest x-ray and asthma biomarkers (fraction of exhaled nitric oxide and blood eosinophil count). Hospital admissions were reduced by 93%, ED attendances by 83.4% and GP OOH visits by 71.4% during the 6-month period following attendance. Conclusions The identification and management of common asthma comorbidities is important and should be routinely assessed. The ARH reduces healthcare utilisation for patients attending with asthma. It could provide additional support to the regional service enabling quicker access to biologic therapies.

Inpatient healthcare utilization in the first year following a childhood cancer diagnosis: A population-based analysis.

11138 Background: Children with cancer may require substantial healthcare resources during treatment, including inpatient care. Hospital utilization patterns at the population level, and factors associated with higher utilization, are not well-described. Methods: We conducted a retrospective cohort analysis of Washington State (WA) cancer registry data (1992-2013) linked to state birth (1974-2013), death (1992-2013), and hospital discharge (1992-2013) records to identify all WA children diagnosed with cancer &lt;20 years. We examined hospitalization frequency and total inpatient bed days in the year after cancer diagnosis. To evaluate factors associated with outcomes of interest, we constructed multivariable negative binomial regression models of children with ≥1 inpatient admission, calculating incidence rate ratios (IRR). Covariates included rural residence (binary; census tract rural-urban commuting area codes), high neighborhood deprivation (binary; state-normative census block group Area Deprivation Index [ADI]), sex, race/ethnicity, diagnosis age, birth year, and cancer type (per International Classification of Childhood Cancer). Due to differences in utilization by cancer type, we also examined children in subanalyses with acute lymphoblastic leukemia (ALL), lymphomas, and solid (including central nervous system [CNS]) tumors. Results: 2,231 children (mean diagnosis age 7.2 years; 68% diagnosed since 2000) had 12,833 inpatient encounters. In the year after diagnosis, children had a median of 4 (IQR 2-8) hospitalizations/year at-risk, and 21 (IQR 8-54) inpatient days (median length of stay 4 days [IQR 2-6]). In multivariable analysis, high ADI (IRR 1.11, 95% CI 1.01-1.21), but not rural residence (IRR 0.95, 95% CI 0.85-1.05), was associated with greater hospitalization frequency. Female sex was associated with lower frequency (IRR 0.94, 95% CI 0.88-1.00). In analysis of total inpatient days, high ADI (IRR 1.15, 95% CI 1.02-1.29) and Hispanic ethnicity (IRR 1.31, 95% CI 1.13-1.51) were independently associated with greater inpatient days. In subanalysis of patients with ALL (N=497), associations between inpatient days and ADI (IRR 1.18, 95% CI 0.99-1.40) and Hispanic ethnicity (IRR 1.01, 0.84-1.23) were no longer significant. For lymphoma (N=259), associations were similar but also no longer significant (ADI IRR 1.14, 95% CI 0.78-1.71; Hispanic IRR 1.26, 95% CI 0.79-2.10). Among patients with solid/CNS tumors (N=1,151), associations with Hispanic ethnicity remained significant (IRR 1.46, 95% CI 1.19-1.80), but not ADI (IRR 1.11, 95% CI 0.95-1.30). Conclusions: Children with cancer spend considerable time inpatient during the year after diagnosis. Disparities in hospital utilization mirror some known disparities in childhood cancer survival. Initiatives to alleviate systemic disadvantages may reduce inpatient utilization for some groups.

Does supplemental private health insurance impact health care utilization and seeking behavior of residents covered by social health insurance? Evidence from China National Health Services Survey

BackgroundSupplemental private health insurance (PHI) plays a crucial role in complementing China’s social health insurance (SHI). However, the effectiveness of incorporating PHI as supplementary coverage lacks conclusive evidence regarding its impact on healthcare utilization and seeking behavior among SHI-covered individuals. Therefore, investigating the effects of supplementary PHI on health care utilization and seeking behavior of residents covered by social health insurance is essential to provide empirical evidence for informed decision-making within the Chinese healthcare system.MethodsData from the 2018 China National Health Services Survey were analyzed to compare outpatient and inpatient healthcare utilization and choices between PHI purchasers and non-purchasers across three SHI schemes: urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), and the new rural cooperative medical scheme (NRCMS). Using the Andersen Healthcare Services Utilization Behavior Model as the theoretical framework,binary logistic regression and multinomial logistic regression (MNL) models were employed to assess the impact of PHI on healthcare utilization and provider preferences.ResultsAmong UEBMI, URBMI, and NRCMS participants with PHI, outpatient visit rates were 17.9, 19.8, and 21.7%, and inpatient admission rates were 12.4, 9.9, and 12.9%, respectively. Participants without PHI exhibited higher rates for outpatient visits (23.6, 24.3, and 25.6%) and inpatient admissions (15.2, 12.8, and 14.5%). Binomial logistic regression analyses revealed a higher probability of outpatient visits and inpatient admissions among UEBMI participants with PHI (p < 0.05). NRCMS participants with PHI showed a lower probability of outpatient visits but a higher probability of inpatient admissions (p < 0.05). Multinomial logistic regression indicated that NRCMS participants with PHI were more likely to choose higher-level hospitals, with a 17% increase for county hospitals and 27% for provincial or higher-level hospitals compared to primary care facilities.ConclusionThe findings indicate that the possession of PHI correlated with increased utilization of outpatient and inpatient healthcare services among participants covered by UEBMI. Moreover, for participants under the NRCMS, the presence of PHI is linked to a proclivity for seeking outpatient care at higher-level hospitals and heightened utilization of inpatient services. These results underscore the nuanced influence of supplementary PHI on healthcare-seeking behavior, emphasizing variations across individuals covered by distinct SHI schemes.

#1002 End of life healthcare utilisation and costs of older patients receiving kidney replacement therapy—analysis of Dutch health insurance claims data

Abstract Background and Aims The increasing prevalence of chronic kidney disease (CKD), an aging population and advancements in treatment options collectively contribute to a rise in older patients with a functioning kidney transplant (KTX) or undergoing dialysis. These treatments are associated with extensive healthcare utilisation, placing substantial demands on both patients and the healthcare system. Healthcare utilisation typically increases near the end of life, and is associated with increased costs. However, little is known about the end-of-life healthcare utilisation of patients receiving kidney replacement therapy (KRT). Therefore, our study aims to assess healthcare utilisation and costs during the last year of life. Method We analysed Dutch health insurance claims data from patients aged &amp;gt;65 years on KRT who deceased between June 2016 and December 2021. We matched each patient with two controls, defined as individuals who died within the same calendar year without any insurance claims related to CKD or KRT. Matching was performed on sex, age and socio-economic status. The primary outcomes were healthcare utilisation and costs in the last twelve months of life for patients treated with different KRT modalities and compared to matched controls. Healthcare utilisation was detailed at hospital and intensive care unit (ICU) admissions, emergency department (ED) and outpatient department (OPD) visits, hospital daycare and institutionalised care. Healthcare costs encompassed costs related to primary care, hospital care (inpatient and outpatient), mental care, institutionalised care, prescription medication, transportation and other costs. Hospital care costs were categorised as KRT-related and -unrelated costs. Results In total 7279 decedents were included; 4614 haemodialysis patients (HD), 766 peritoneal dialysis (PD) patients and 1899 KTx recipients. KRT patients had a mean age of 77.6 ± 6.6 years, with 64% being male, and had significantly more comorbidities than the control group. In the year preceding death, KRT patients had significantly more hospital admissions, ICU admissions, ED visits, outpatient visits, hospital daycare and institutionalised care than controls (see Fig. 1). When comparing across KRT-modalities, KTx patients were more often admitted to the ICU than HD and PD patients (p = 0.001 and p = 0.024, respectively). For both HD, PD and KTx patients, the mean number of days admitted to the hospital and ICU, as well as ED visits and OPD visits significantly increased in last three months preceding death, compared to the initial nine months of the last year of life (p &amp;lt; 0.0001). Mean total healthcare costs in the last year of life were €59.489 for KTx patients, €108.294 for PD and €117.520 for HD patients, compared to €19.820 for the controls. The majority of costs for dialysis patients were attributed to KRT, accounting for 55.5% (€65.216) and 60.0% (€64.559) of the total expenditures for HD and PD patients, respectively. In contrast, KRT-related costs constituted 25.7% (€15.262) of the total expenses in KTx patients. Besides substantial KRT-related costs, KRT-patients also incurred higher costs for specialist care in the hospital, primary care, medication and transport, compared to controls. Conclusion Healthcare utilisation is substantial for older KRT patients and intensifies during the last year of life. This is accompanied with elevated costs. Further research is necessary to evaluate the impact of healthcare utilisation on the quality of life and whether advanced care planning could prevent overutilisation.

Is gender dysphoria associated with increased hospital cost per stay among patients hospitalized for depression? Focus on the racial and regional variance in US hospitals

IntroductionIndividuals with gender dysphoria do not identify with their sex assigned at birth and face societal and cultural challenges, leading to increased risk for depression, anxiety, and suicide. Gender dysphoria is a DSM-5 diagnosis but is not necessary for transition therapy. Additionally, individuals with gender dysphoria or who identify as gender diverse/nonconforming may experience “minority stress” from increased discrimination, leading to a greater risk for mental health problems. This study aimed to identify possible health disparities in patients hospitalized for depression with gender dysphoria across the United States. Depression was selected because patients with gender dysphoria are at an increased risk for it. Various patient and hospital-related factors are explored for their association with changes in healthcare utilization for patients hospitalized with depression.MethodsThe National Inpatient Sample was used to identify nationwide patients with depression (n = 378,552, weighted n = 1,892,760) from 2016 to 2019. We then examined the characteristics of the study sample and investigated how individuals’ gender dysphoria was associated with healthcare utilization measured by hospital cost per stay. Multivariate survey regression models were used to identify predictors.ResultsAmong the 1,892,760 total depression inpatient samples, 14,145 (0.7%) patients had gender dysphoria (per ICD-10 codes). Over the study periods, depression inpatients with gender dysphoria increased, but total depression inpatient rates remained stable. Survey regression results suggested that gender dysphoria, minority ethnicity or race, female sex assigned at birth, older ages, and specific hospital regions were associated with higher hospital cost per stay than their reference groups. Sub-group analysis showed that the trend was similar in most racial and regional groups.ConclusionDifferences in hospital cost per stay for depression inpatients with gender dysphoria exemplify how this community has been disproportionally affected by racial and regional biases, insurance denials, and economic disadvantages. Financial concerns can stop individuals from accessing gender-affirming care and risk more significant mental health problems. Increased complexity and comorbidity are associated with hospital cost per stay and add to the cycle.

Long-term clinical outcomes in patients with CIS treated with interferon beta-1b: results from the 15-year follow up of the BENEFIT trial

Multiple sclerosis (MS) treatment intervention with immunomodulating therapy at early disease stage improves short term clinical outcomes. The objective of this study is to describe the long-term outcomes and healthcare utilization of patients with clinically isolated syndrome (CIS) included in the Betaferon®/Betaseron® in Newly Emerging MS for Initial Treatment (BENEFIT) randomized, parallel group trial. In BENEFIT patients were assigned to “early” IFNB-1b treatment or placebo (“delayed” treatment). After 2 years or conversion to clinically definite multiple sclerosis (CDMS), all patients were offered IFNB-1b and were reassessed 15 years later. Of 468 patients, 261 (55.8%) were enrolled into BENEFIT 15 (161 [55.1%] from the early, 100 [56.8%] from the delayed treatment arm). In the full BENEFIT analysis set, risk of conversion to CDMS remained lower in the early treatment group ( – 30.5%; hazard ratio 0.695 [95% CI, 0.547–0.883]; p = 0.0029) with a 15.7% lower risk of relapse than in the delayed treatment group (p = 0.1008). Overall, 25 patients (9.6%; 9.9% early, 9.0% delayed) converted to secondary progressive multiple sclerosis. Disability remained low and stable with no significant difference between groups in Expanded Disability Status Scale score or MRI metrics. Paced Auditory Serial Addition Task-3 scores were better in the early treatment group (p = 0.0036 for treatment effect over 15 years). 66.3% of patients were still employed at Year 15 versus 74.7% at baseline. In conclusion, results 15 years from initial randomization support long-term benefits of early treatment with IFNB-1b.

Inpatient Palliative Care and Healthcare Utilization Among Older Patients With Alzheimer's Disease and Related Dementia (ADRD) and High Risk of Mortality in U.S. Hospitals.

Background. Despite the potential of palliative care (PC) to enhance the quality of life for patients with advanced dementia, there is limited knowledge of its inpatient utilization patterns. This study investigated inpatient PC consultation utilization patterns and evaluated its impact on hospital length of stay (LOS) and medical costs among older patients diagnosed with Alzheimer's Disease and Related Dementia who were at a high risk of mortality (ADRD-HRM). Methods. Using the 2016-2019 National Inpatient Sample database, we conducted multivariable logistic regression analyses to identify individual and hospital characteristics influencing PC consultation utilization. We subsequently performed generalized linear models to estimate LOS (using Poisson distribution) and hospital charges (via log-transformation). Results. Our sample encompassed 965,644 hospital discharges (weighted n = 4,828,219) of patients aged 65years and above with ADRD-HRM. Among them, 14.6% received inpatient PC. There was a notable uptrend in PC consultation utilization from 13.3% in 2016 to 16.3% in 2019 (p trend<.001). Factors positively influencing and associated with PC utilization included patients that are older, non-Hispanic White, with higher income, receiving care from teaching hospitals, and facilitated with greater bed capacity (all P < .05). Although patients who received PC were more likely to have 3.0% longer LOS (P < .001), they had 19.2% lower hospital charges (P < .001). Conclusions. PC substantially reduced hospital expenditures for older patients with ADRD-HRM, but the prevalence remained low at 14.6% in the study period. Future studies should explore the unmet needs of patients with lower sociodemographic status and those in rural hospitals to further increase their PC consultation utilization.

Prognostic Factors and Treatment Effect Modifiers for Physical Health, Opioid Prescription, and Health Care Utilization in Patients With Musculoskeletal Disorders in Primary Care: Exploratory Secondary Analysis of the STEMS Randomized Trial of Direct Access to Physical Therapist-Led Care.

The aims of the study were to identify prognostic factors associated with health care outcomes in patients with musculoskeletal (MSK) conditions in primary care and to determine whether characteristics associated with choice of care modify treatment effects of a direct-access physical therapist-led pathway in addition to general practitioner (GP)-led care compared to GP-led care alone. A secondary analysis of a 2-parallel-arm, cluster randomized controlled trial involving general practices in the United Kingdom was conducted. Practices were randomized to continue offering GP-led care or to also offer a direct-access physical therapist-led pathway. Data from adults with MSK conditions who completed the 6-month follow-up questionnaire were analyzed. Outcomes included physical health, opioid prescription, and self-reported health care utilization over 6months. Treatment effect modifiers were selected a priori from associations in observational studies. Multivariable regression models identified potential prognostic factors, and interaction analysis tested for potential treatment effect modifiers. Analysis of 767 participants indicated that baseline pain self-efficacy, pain severity, and having low back pain statistically predicted outcomes at 6months. Higher pain self-efficacy scores at baseline were associated with improved physical health scores, reduced opioid prescription, and less health care utilization. Higher bodily pain at baseline and having low back pain were associated with worse physical health scores and increased opioid prescription. Main interaction analyses did not reveal that patients' age, level of education, duration of symptoms, or MSK presentation influenced response to treatment, but visual trends suggested those in the older age group proceeded to fewer opioid prescriptions and utilized less health care when offered direct access to physical therapy. Patients with MSK conditions with lower levels of pain self-efficacy, higher pain severity, and presenting with low back pain have less favorable clinical and health care outcomes in primary care. Prespecified characteristics did not modify the treatment effect of the offer of a direct-access physical therapist-led pathway compared to GP-led care. Patients with MSK conditions receiving primary care in the form of direct-access physical therapist-led or GP-led care who have lower levels of self-efficacy, higher pain severity, and low back pain are likely to have a less favorable prognosis. Age and duration of symptoms should be explored as potential patient characteristics that modify the treatment response to a direct-access physical therapist-led model of care.

Characteristics and Health Care Utilization of Patients With Housing Insecurity in the ED

Unstable housing and homelessness can exacerbate adverse health outcomes leading to increased risk of chronic disease, injury, and disability. However, emergency departments (EDs) have no universal method to identify those at risk of or currently experiencing homelessness. To describe the extent of housing insecurity among patients who seek care in an urban ED, including chief concerns, demographics, and patterns of health care utilization. This cross-sectional study included all adult patients presenting to the ED at Vanderbilt University Medical Center (VUMC), an urban tertiary care, level I trauma center in the Southeast US, from January 5 to May 16, 2023. The primary outcome was the proportion of ED visits at which patients screened positive for housing insecurity. Secondary outcomes included prevalence of insecurity by chief concerns, demographics, and patterns of health care utilization. Of all 23 795 VUMC ED visits with screenings for housing insecurity (12 465 visits among women [52%]; median age, 47 years [IQR, 32-48 years]), in 1185 (5%), patients screened positive for current homelessness or housing insecurity (660 unique patients); at 22 610 visits (95%), the screening result was negative. Of visits with positive results, the median age of patients was 46 years (IQR, 36-55 years) and 829 (70%) were among male patients. Suicide and intoxication were more common chief concerns among visits at which patients screened positive (132 [11%] and 118 [10%], respectively) than among those at which patients screened negative (220 [1%] and 335 [2%], respectively). Visits with positive results were more likely to be among patients who were uninsured (395 [33%] vs 2272 [10%]) and had multiple visits during the study period. A higher proportion of positive screening results occurred between 8 pm and 6 am. The social work team assessed patients at 919 visits (78%) with positive screening results. In this cross-sectional study of 23 795 ED visits, at 5% of visits, patients screened positive for housing insecurity and were more likely to present with a chief concern of suicide, to be uninsured, and to have multiple visits during the study period. This analysis provides a call for other institutions to introduce screening and create tailored care plans for patients experiencing housing insecurity to achieve equitable health care.

54 Real-World Evaluation of Healthcare Utilization in Patients with a Positive Molecular Diagnosis for Inborn Errors of Immunity

54 Real-World Evaluation of Healthcare Utilization in Patients with a Positive Molecular Diagnosis for Inborn Errors of Immunity

Rural–urban inequalities in health care utilization in Bhutan: a decomposition analysis

Background and objectiveOn the trajectory towards universal health coverage in Bhutan, health equity requires policy attention as significant disparities exist between urban and rural health outcomes. This paper examines health services utilization patterns, inequalities and their socio-economic determinants in rural and urban areas and decomposes the factors behind these differences.MethodsWe used the Bhutan Living Standard Survey 2017 to profile health services utilization patterns and equalities. We employed two different decomposition analyses: decomposition of mean differences in utilization using the Oaxaca–Blinder decomposition framework and differences in the income-related distribution in utilization using recentered influence function regressions between rural and urban areas.ResultsSignificant differences exist in the type of outpatient services used by the rural and urban population groups, with those living in rural areas having 3.4 times higher odds of using primary health centers compared to outpatient hospital care. We find that the use of primary health care is pro-poor and that outpatient hospital resources is concentrated among the more affluent section of the population, with this observed inequality consistent across settings but more severe in rural areas. The rural–urban gap in utilization is primarily driven by income and residence in the eastern region, while income-related inequality in utilization is influenced, aside from income, by residence in the central region, household size, and marriage and employment status of the household head. We do not find evidence of significant mean differences in overall utilization or inequality in utilization of inpatient health care services.ConclusionsWhile the differences in average contacts with health services are insignificant, there are prominent differences in the level of services availed and the associated inequality among rural and urban settings in Bhutan. Besides, while there are obvious overlaps, factors influencing income-related inequality are not necessarily the same as those driving the utilization gaps. Cognizance of these differences may lead to better informed, targeted, and potentially more effective future research and policies for universal health coverage.

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)

Epistaxis Rates and Health Care Utilization in Patients With a Ventricular Assist Device.

Identify baseline epistaxis rates and epistaxis-related health care utilization trends in the ventricular assist device (VAD) population. Single center, retrospective cohort study consisting of chart review of adult VAD patients. Analysis of descriptive statistics was assessed using χ 2 tests, independent sample t tests, or Fisher's exact when expected counts were low. Logistic regression was used to assess associations between epistaxis and variables of interest. Two hundred ninety patients were included in the analysis. Ninety-eight (33.8%) patients developed epistaxis and 84 (29.0%) received medical attention. Patients with gastrointestinal (GI) bleeding had increased rates of epistaxis (42.4% vs 29.0%). Logistic regression analysis found GI bleeding to have an adjusted odds of developing epistaxis of 1.94 (95% confidence interval [CI]: 1.12-3.37) and kidney disease to have an adjusted odds of 1.83 (95% CI: 1.06, 3.13). VAD implantation improves survival and quality of life but also carries significant bleeding risks. At our institution, 29% of VAD patients received medical attention for epistaxis. GI bleeding and kidney disease were found to have increased adjusted odds of developing epistaxis. Fifty-nine percent of epistaxis events occurred while inpatient and 32.8% of events were seen in the emergency department. VAD patients are an at-risk group that could potentially benefit from preventative nasal hydration regimen.

Enhancing Communication in Critically Ill Patients with a Tracheostomy: A Systematic Review of Evidence-Based Interventions and Outcomes.

Tracheostomy, a common procedure performed in intensive care units (ICU), is associated with communication impairment and affects patient well-being. While prior research has focused on physiological care, there is a need to address communication needs and quality of life (QOL). We aimed to evaluate how different types of communication devices affect QOL, speech intelligibility, voice quality, time to significant events, clinical response and tolerance, and healthcare utilization in patients undergoing tracheostomy. Following PRISMA guidelines, a systematic review was conducted to assess studies from 2016 onwards. Eligible studies included adult ICU patients with a tracheostomy, comparing different types of communication devices. Data were extracted and synthesized to evaluate QOL, speech intelligibility, voice quality, time to significant events (initial communication device use, oral intake, decannulation), clinical response and tolerance, and healthcare utilization and facilitators/barriers to device implementation. Among 9,228 studies screened, 8 were included in the review. Various communication devices were employed, comprising both tracheostomy types and speaking valves, highlighting the multifaceted nature of interventions. Quality of life improvements were observed with voice restoration interventions, but challenges such as speech intelligibility impairments were noted. The median time for initial communication device usage post-intervention was 11.4 ± 5.56 days. The median duration of speech tolerance ranged between 30-60 minutes to 2-3 hours across different studies. Complications such as air trapping or breathing difficulties were reported in 15% of cases. Additionally, the median ICU length of stay post-intervention was 36.5 days. Key facilitators for device implementation included early intervention, while barriers ranged from service variability to physical intolerance issues. Findings demonstrate that various types of communication devices can significantly enhance the quality of life, speech intelligibility, and voice quality for patients undergoing tracheostomy, aligning with the desired outcomes of improved clinical response and reduced healthcare utilization. The identification of facilitators and barriers to device implementation further informs clinical practice, suggesting a tailored, patient-centered approach is crucial for optimizing the benefits of communication devices in this population.

Association of licensure and relationship requirement waivers with out-of-state tele-mental health care, 2019-2021.

During the COVID-19 public health emergency, states waived in-state licensure and pre-existing patient-physician relationship requirements to increase access to care. We exploit this state telehealth policy variation to estimate the association of in-state licensure requirement waivers and pre-existing patient-physician relationship requirement waivers with out-of-state tele-mental health care utilization of patients diagnosed with COVID-19. Using claims from January 2019 until December 2021 of 2 037 977 commercially insured individuals in 3 metropolitan statistical areas (MSAs) straddling Midwestern state borders, we found increased out-of-state telehealth utilization as a share of out-of-state mental health care by 0.1411 and 0.0575 visits per month or 1679.76% and 467.48% after licensure and relationship waivers, respectively. Within-MSA analyses illustrate an urban-rural digital divide in out-of-state utilization as a share of total or telehealth mental health care. Our findings indicate waivers primarily enhance access to care of established patients by enabling the transition of in-person out-of-state health care online. Interstate medical licensure compact participation may provide broader access to out-of-state tele-mental health care than emergency waivers.

Identifying future high healthcare utilization in patients with multimorbidity – development and internal validation of machine learning prediction models using electronic health record data

PurposeTo develop and internally validate prediction models with machine learning for future potentially preventable healthcare utilization in patients with multiple long term conditions (MLTC). This study is the first step in investigating whether prediction models can help identify patients with MLTC that are most in need of integrated care.MethodsA retrospective cohort study was performed with electronic health record data from adults with MLTC from an academic medical center in the Netherlands. Based on demographic and healthcare utilization characteristics in 2017, we predicted ≥ 12 outpatient visits, ≥ 1 emergency department (ED) visits, and ≥ 1 acute hospitalizations in 2018. Four machine learning models (elastic net regression, extreme gradient boosting (XGB), logistic regression, and random forest) were developed, optimized, and evaluated in a hold-out dataset for each outcome.ResultsA total of 14,486 patients with MLTC were included. Based on the area under the curve (AUC) and calibration curves, the XGB model was selected as final model for all three outcomes. The AUC was 0.82 for ≥ 12 outpatient visits, 0.76 for ≥ 1 ED visits and 0.73 for ≥ 1 acute hospitalizations. Despite adequate AUC and calibration, precision-recall curves showed suboptimal performance.ConclusionsThe final selected models per outcome can identify patients with future potentially preventable high healthcare utilization. However, identifying high-risk patients with MLTC and substantiating if they are most in need of integrated care remains challenging. Further research is warranted investigating whether patients with high healthcare utilization are indeed the most in need of integrated care and whether quantitively identified patients match the identification based on clinicians’ experience and judgment.