scholarly journals LO047: Predictors of treatment failure in renal colic patients discharged from the emergency department

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S46-S46
Author(s):  
G. Innes ◽  
J. Andruchow ◽  
A. McRae ◽  
T. Junghans ◽  
E. Lang
Keyword(s):  
Treatment Failure ◽  
Outpatient Treatment ◽  
Renal Colic ◽  
Hospital Admissions ◽  
Symptom Control ◽  
Vital Signs ◽  
Acute Renal Colic ◽  
Ed Visits ◽  
One Year ◽  
Stone Characteristics

Introduction: Most patients with acute renal colic are discharged from the ED after initial diagnosis and symptom control, but 20-30% require repeat ED visits for ongoing pain, and 15-25% require rescue intervention (ureteroscopic intervention or lithotripsy). If patients destined for failure of outpatient management could be identified based on information available during their ED visits, they could be prioritized early for intervention to reduce short term pain and disability. Our objective was to identify predictors of outpatient treatment failure, defined as the need for hospitalization or rescue intervention within 60 days of ED discharge. Methods: We collated prospectively gathered administrative data from all Calgary region patients with an ED diagnosis of renal colic over a one-year period. Demographics, arrival mode, triage category, vital signs, pain scores, analgesic use and ED disposition were recorded. Research assistants reviewed imaging reports and documented stone characteristics. These data were linked with regional hospital databases to identify ED revisits, hospital admissions, and surgical procedures. The primary outcome was hospitalization or rescue intervention within 60 days of ED discharge. Results: Of 3104 patients with first ED visit for acute renal colic, 1296 had CT or US imaging and were discharged without intervention. Median age was 50 years and 69% were male. 325 patients (25.1%) required an ED re-visit and 11.8% required admission or rescue intervention. Patients with small (<5mm), medium (5-7mm) and large (>7mm) stones failed in 9.0%, 14.4% and 9.9% of cases respectively. The only factor predictive of treatment failure in multivariable models was stone position in the proximal or mid-ureter. Age, sex, vital signs, pain score, WBC, creatinine, history of prior stone or intervention, stone side, stone size, presence of stranding and degree of hydronephrosis were not associated with outpatient failure. Conclusion: Outpatient treatment failure could not be predicted based on any of the predictors studied.

scholarly journals MP52: Effectiveness of an outpatient parenteral antibiotic therapy clinic for adults with non-purulent cellulitis

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S61-S61
Author(s):  
A. Mattice ◽  
R. Yip ◽  
D. Eagles ◽  
H. Rosenberg ◽  
K. Suh ◽  
...  
Keyword(s):  
Adverse Events ◽  
Antibiotic Therapy ◽  
Hospital Admission ◽  
Treatment Failure ◽  
Post Intervention ◽  
Parenteral Antibiotic ◽  
Monthly Data ◽  
Outpatient Parenteral Antibiotic Therapy ◽  
Ed Visits ◽  
One Year

Introduction: Emergency department (ED) patients with cellulitis that are treated with intravenous (IV) antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective of this study was to determine whether the implementation of an OPAT clinic results in decreased hospitalization and return ED visits for patients treated with IV antibiotics. Methods: We conducted a before-after implementation study involving adults (age >=18 years) that presented to two tertiary care EDs with cellulitis and were treated with IV antibiotics. The intervention was referral to an infectious disease physician within one week of the index ED visit at the newly created OPAT clinic. The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after 48 hours of OPAT) and adverse events (e.g. vomiting, diarrhea). We conducted an interrupted time series analysis from January to December both pre-intervention (2013) and post-intervention (2015), with 24 monthly data points. The year of clinic implementation (2014) was considered a transition period. A segmented non-linear regression autoregressive error model was used to aggregate the monthly data to evaluate the effectiveness of the intervention. Results: A total of 1,666 patients met inclusion criteria: 858 pre-intervention (mean age 59 years, 53.1% male) and 808 post-intervention (mean age 62 years, 54.5% male). Hospitalization rates were not significantly higher one year after clinic implementation (p = 0.53) although there was a non-statistically significant gradual increase of 0.8% per month (95%CI -0.3% to 1.9%). One year after introduction of the OPAT clinic, return ED visits were significantly lower (change in intercept -24.4%, 95%CI -34.2% to -14.6%; p < 0.001), followed by an additional drop of 1.4% per month (95%CI -2.1% to -0.6%; p = 0.002). By the end of the study, return visits were 40.7% lower (95%CI 25.6% to 55.9%) than if the intervention had not been introduced. Treatment failure rates were <2% and adverse events were <5% in both groups. Conclusion: Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, which is critically important given the current ED overcrowding crisis. There was no significant change in hospital admission rates. There were low rates of treatment failures and adverse events. An OPAT clinic should be considered to reduce ED crowding while maintaining safe patient care.

Machine learning-based approach to the risk assessment of potentially preventable outpatient cancer treatment-related emergency care and hospitalizations.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 333-333
Author(s):  
Kevin Miao ◽  
Justice Dahle ◽  
Sasha Yousefi ◽  
Bilwa Buchake ◽  
Parambir Kaur ◽  
...  
Keyword(s):  
Machine Learning ◽  
Random Forest ◽  
Acute Care ◽  
Systemic Therapy ◽  
Hospital Admissions ◽  
Vital Signs ◽  
Predictive Ability ◽  
Roc Curves ◽  
Infusion Chemotherapy ◽  
Ed Visits

333 Background: Patients undergoing outpatient infusion chemotherapy for cancer are at risk for potentially preventable, unplanned acute care in the form of emergency department (ED) visits and hospital admissions. This can impact outcomes, patient decisions, and costs to the patient and healthcare system. To address this need, the Centers for Medicare & Medicaid Services developed the Chemotherapy Measure (OP-35). Recent randomized controlled data indicate that electronic health record (EHR)-based machine learning (ML) approaches accurately direct supportive care to reduce acute care during radiotherapy. As this may extend to systemic therapy, this study aims to develop and evaluate ML approaches to predict the risk of OP-35 qualifying, potentially preventable acute care within 30 days of infusional systemic therapy. Methods: This study included data from UCSF cancer patients receiving infusional chemotherapy from July 1, 2017, to February 11, 2021, (total 7,068 patients over 84,174 treatments). The data incorporated into the ML included 430 EHR-derived variables, including cancer diagnosis, therapeutic agents, laboratory values, vital signs, medications, and encounter history. Three ML approaches were trained to predict an OP-35 acute care risk following a systemic therapy infusion with least absolute shrinkage selection operator (LASSO), random forest, and gradient boosted trees (GBT; XGBoost) approaches. The models were trained on a subset (75% of patients; before October 12, 2019) of the dataset and validated on a mutually exclusive subset (25% patients; after October 12, 2019) based on the receiver operating characteristic (ROC) curves and calibration plots. Results: There were 1,651 total acute care visits (244 ED visits and 1,407 ED visits converted into hospitalization); 1,310 infusions included a qualifying acute care visit (200 with ED visits only, 0 direct hospital admissions, and 1,110 with both ED visit and hospitalization). Each ML approach demonstrated good performance in the internal validation cohort, with GBT (AUC 0.805) outpacing the random forest (0.750) and LASSO logistic regression (0.755) approaches. Visualization of calibration plots verified concordance between predicted and observed rates of acute care. All three models shared patient age and days elapsed since last treatment as important contributors. Conclusions: EHR-based ML approaches demonstrate high predictive ability for OP-35 qualifying acute care rates on a per-infusion basis, identifying 30-day potentially preventable acute care risk for patients undergoing chemotherapy. Prospective validation of these models is ongoing. Early prediction can facilitate interventional strategies which may reduce acute care, improve health outcomes, and reduce costs.

LO02: Heart failure and palliative care in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S27-S28
Author(s):  
M. Lipinski ◽  
D. Eagles ◽  
L.M. Fischer ◽  
L. Mielneczuk ◽  
I.G. Stiell
Keyword(s):  
Heart Failure ◽  
Palliative Care ◽  
High Risk ◽  
Mortality Rate ◽  
Hospital Admissions ◽  
Mortality And Morbidity ◽  
Early Palliative Care ◽  
Icd 10 ◽  
Ed Visits ◽  
One Year

Introduction: Heart failure (HF) is a common ED presentation that is associated with significant morbidity and mortality. Despite recent evidence and recommendations for early palliative care (PC) involvement in these patients, they are still significantly under-served by PC services, often resulting in multiple ED visits. We sought to evaluate use of PC services in patients with HF presenting to the ED. Secondary objectives of the study were to investigate: 1) one year mortality, ED visits, and admissions; 2) application of a novel palliative care referral score. Methods: We conducted a health records review of 500 consecutive HF patients who presented to two academic hospital EDs. We included patients aged 65 years or older who were diagnosed as having a HF exacerbation by the emergency physician (ICD-10 code 150.-). Our primary outcome was PC involvement. Secondary outcomes included one year mortality rates, ED visits, admissions to hospital, as well as the application of a novel PC referral score developed by the institutional cardiac Palliative Care Committee. The score consisted of 6 different aspects of the patient’s illness, including laboratory tests, hospital usage, and markers of decompensation. We conducted appropriate univariate analyses. Results: Patients were mean age 80.7 years, women (53.2%), and had significant comorbidities (atrial fibrillation (51.2%), diabetes (40.4%) and COPD (20.8%)). Compared to those with no PC, the 79 (15.8%) patients with PC involvement had a higher one year mortality rate (70.9% vs. 18.8%, p&lt;0.0001), more ED visits/year for HF (0.82 vs. 0.52, p&lt;0.0001), and more hospital admissions/year for HF (1.4 vs. 0.85, p&lt;0.0001). Using the heart failure palliative care score criteria, 60 patients had scores &gt;=2. Compared to those with scores &lt;2, these patients had a higher 1-year mortality rate (50% vs. 24%, p&lt;0.0001) and more ED visits/year for HF (0.83 vs. 0.54, p&lt;0.01). Only 40.0% of these high risk patients had any PC involvement. Conclusion: We found that few HF patients had PC services involved in their care. Using this novel HF palliative care referral score, we were able to identify patients with a significantly greater risk of mortality and morbidity. This study provides evidence that the ED is an appropriate setting to identify and refer high risk HF patients who would likely benefit from earlier PC involvement and may be a future avenue for PC access for these patients.

Resource Use and Expenditures Among Adult Sickle Cell Patients with and without Depression

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 1534-1534 ◽  
Author(s):  
Shital Kamble ◽  
Shelby D Reed ◽  
Charlene Flahiff ◽  
Soheir Adam ◽  
Laura M DeCastro
Keyword(s):  
Health Care ◽  
Health Care Utilization ◽  
Resource Use ◽  
Hospital Admissions ◽  
Study Entry ◽  
Care Utilization ◽  
Outpatient Visits ◽  
Ed Visits ◽  
Time Periods ◽  
One Year

Abstract Abstract 1534 Objective: Depression is commonly associated with less favorable medical outcomes among patients with sickle cell disease (SCD), yet little is known about its associated impact on medical resource use and expenditures. In this study, we descriptively compared inpatient stays, number of hospital admissions, emergency department (ED) visits, outpatient visits, and expenditures for SCD patients with and without depression. Methods: 150 adult SCD patients were prospectively enrolled in a cross-sectional cohort study in 2009 to evaluate the prevalence of depression and its association with quality of life, disease severity scores measuring end organ damage, and health care utilization. Detailed cost accounting and administrative physician billing records from the Duke University Health System were obtained for all enrolled patients and used to generate estimates of medical care utilization and costs. Indexing on the enrollment date, we included data representing one year prior to and six months following study entry. Based on the Beck Depression Inventory (BDI) scores, we categorized SCD patients into those with depression (BDI score ≥14) and those without depression (BDI score <14). Given the skewed distributions of resource use and expenditures, we used generalized linear regression models (GLM) with negative binomial distributions and log links to compare inpatient stays, number of hospital admissions, ED visits, and outpatient visits and GLMs with gamma distributions and log links to compare costs associated with each resource use category between patients with and without depression. Results: Data from 142 patients analyzed, 81 females and 61 males with a mean age of 34.2 years. We identified 50 patients with depression and 92 patients without depression. At study entry, females represented 72% of SCD patients with depression and 49% of SCD patients without depression (P< 0.01). Median age was 32.5 years among patients with depression and 29.5 years among those without depression (P= 0.22). Hospital admissions, ED visits, and outpatient visits were generally similar between patients with and without depression one year prior to and six months after study entry. Patients with depression spent more days in the hospital during both time periods. Total inpatient expenditures, including physician fees paid, were higher for patients with depression than those without depression for both time periods (Table). Conclusion: SCD patients with depression incur higher expenditures and longer stays than SCD patients without depression. Efforts should be made for early diagnosis and active therapeutic intervention for depression among SCD patients, to decrease health care utilization and cost. Disclosures: No relevant conflicts of interest to declare.

scholarly journals 526. Implementation of Use of Monoclonal Antibody Therapy in a Large Academic Center for the Outpatient Treatment of Covid-19: Impact on 30 Day Hospitalization Rates, ED Visits and Death

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S364-S364
Author(s):  
Azra Bhimani ◽  
Vinay Srinivasan ◽  
Stacey Weinstein ◽  
Nathan Clemons ◽  
Quanna Batiste ◽  
...  
Keyword(s):  
Emergency Department ◽  
Monoclonal Antibody ◽  
Treatment Failure ◽  
Real World ◽  
Hospital Admissions ◽  
Antibody Therapy ◽  
Outpatient Setting ◽  
Hospitalized Patients ◽  
Monoclonal Antibody Therapy ◽  
Ed Visits

Abstract Background Monoclonal Antibody Therapy (MAbs) has been shown to reduce rates of ED visits and hospitalizations in patients at risk for severe Covid-19 infection in clinical trials. Since November, three Mabs received emergency use authorization: Bamlanivimab (Bam), Bamlanivimab/Etesevimab (Bam/Ete) and Casirivimab/Imdevimab (Casi/imdevi). We describe here the real-world effectiveness of implementing early MAb therapy in the outpatient setting for individuals with Covid-19 at high risk of progression. Methods We examined the records of 808 UCLA Health patients with a confirmed positive SARS-CoV2 PCR test who were either referred for outpatient Mab therapy or received Mab treatment in the emergency department (ED) between December 10, 2020, and May 3, 2021. The primary outcome of our analysis was the combined 30-day incidence of emergency department visits, hospitalizations, or death following the date of referral. SARS-CoV2 isolates of hospitalized patients who had received Mabs were sequenced to determine the presence of variants. Results Of 808 patients, 383 were referred for treatment but did not receive treatment, 109 received Mabs in the ED and 316 patients were treated in an outpatient setting. Composite 30-day mortality, ED visits and hospital admissions were significantly reduced in the combination therapy group (Bam/Ete or Cas/Imd) compared with monotherapy (Bam alone) or no treatment groups (aHR 0.16, 95% CI .038, .67). Significant factors associated with the composite outcome included: history of lung disease (HR 4.46, 95% CI 2.89-6.90), cardiovascular disease (HR 1.87, 95% CI 1.12-3.12), kidney disease (HR 2.04, 95% CI 1.27-3.25), and immunocompromised state (HR 3.24, 95% CI 1.02-10.26) as well as high social vulnerability index (HR 1.87, 95% CI 1.13-3.10). Over one-third of hospitalized patients who had received Mabs were confirmed to have the California variant (B.1.427/29) (Figure 1). Figure 1. Covid-19 MAB Treatment Failure Lineages Conclusion Our data show that in a real-world setting, combination monoclonal antibody therapy, not monotherapy, significantly reduced ED visits and hospital admissions, likely due to the presence of the California variants. High socioeconomic vulnerability and certain medical conditions increased risk of treatment failure. Disclosures Omai Garner, PhD, D(ABMM), Beckman Coulter (Scientific Research Study Investigator)

scholarly journals Biomarkers-based personalized follow-up in chronic heart failure improves patient’s outcomes and reduces care associate cost

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Antonio Leon-Justel ◽  
Jose I. Morgado Garcia-Polavieja ◽  
Ana Isabel Alvarez-Rios ◽  
Francisco Jose Caro Fernandez ◽  
Pedro Agustin Pajaro Merino ◽  
...  
Keyword(s):  
Heart Failure ◽  
Hospital Admissions ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Secondary Outcome ◽  
Ventricular Ejection Fraction ◽  
Number Of Patients ◽  
Ed Visits ◽  
The Impact

Abstract Background Heart failure (HF) is a major and growing medical and economic problem, with high prevalence and incidence rates worldwide. Cardiac Biomarker is emerging as a novel tool for improving management of patients with HF with a reduced left ventricular ejection fraction (HFrEF). Methods This is a before and after interventional study, that assesses the impact of a personalized follow-up procedure for HF on patient’s outcomes and care associated cost, based on a clinical model of risk stratification and personalized management according to that risk. A total of 192 patients were enrolled and studied before the intervention and again after the intervention. The primary objective was the rate of readmissions, due to a HF. Secondary outcome compared the rate of ED visits and quality of life improvement assessed by the number of patients who had reduced NYHA score. A cost-analysis was also performed on these data. Results Admission rates significantly decreased by 19.8% after the intervention (from 30.2 to 10.4), the total hospital admissions were reduced by 32 (from 78 to 46) and the total length of stay was reduced by 7 days (from 15 to 9 days). The rate of ED visits was reduced by 44% (from 64 to 20). Thirty-one percent of patients had an improved functional class score after the intervention, whereas only 7.8% got worse. The overall cost saving associated with the intervention was € 72,769 per patient (from € 201,189 to € 128,420) and €139,717.65 for the whole group over 1 year. Conclusions A personalized follow-up of HF patients led to important outcome benefits and resulted in cost savings, mainly due to the reduction of patient hospitalization readmissions and a significant reduction of care-associated costs, suggesting that greater attention should be given to this high-risk cohort to minimize the risk of hospitalization readmissions.

Functional Decline in Emergency Department Patients with Dyspnea; a Register-Based Cohort

2021 ◽  
Author(s):  
Karoline Stentoft Rybjerg Larsen ◽  
Marianne Lisby ◽  
Hans Kirkegaard ◽  
Annemette Krintel Petersen
Keyword(s):  
Emergency Department ◽  
Electronic Patient Record ◽  
Hospital Admissions ◽  
Functional Decline ◽  
Patient Characteristics ◽  
Risk Of Death ◽  
Record Data ◽  
Emergency Department Patients ◽  
One Year ◽  
Historic Cohort

Abstract Background Functional decline is associated with frequent hospital admissions and elevated risk of death. Presumably patients acutely admitted to hospital with dyspnea have a high risk of functional decline. The aim of this study was to describe patient characteristics, hospital trajectory, and use of physiotherapy services of dyspneic patients in an emergency department. Furthermore, to compare readmission and death among patients with and without a functional decline, and to identify predictors of functional decline. Methods Historic cohort study of patients admitted to a Danish Emergency Department using prospectively collected electronic patient record data from a Business Intelligence Registry of the Central Denmark Region. The study included adult patients that due to dyspnea in 2015 were treated at the emergency department (ED). The main outcome measures were readmission, death, and functional decline. Results In total 2,048 dyspneic emergency treatments were registered. Within 30 days after discharge 20% was readmitted and 3.9% had died. Patients with functional decline had a higher rate of 30-day readmission (31.2% vs. 19.1%, p&lt;0.001) and mortality (9.3% vs. 3.6%, p=0.009) as well as mortality within one year (36.1% vs. 13.4%, p&lt;0.001). Predictors of functional decline were age ≥60 years and hospital stay ≥6 days. Conclusion Patients suffering from acute dyspnea are seen at the ED at all hours. In total one in five patients were readmitted and 3.9% died within 30 days. Patients with a functional decline at discharge seems to be particularly vulnerable.

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