ECMO use in Germany: An analysis of 29,929 ECMO runs

Background Extracorporeal Membrane Oxygenation (ECMO) use is increasing despite limited evidence. The aim of this study was to demonstrate heterogeneity of ECMO use and its association with hospital size and annual frequency in Germany. Methods This is a database analysis of all ECMO cases in Germany from 2010 to 2016 using the German Diagnosis Related Groups (DRG) coding system for ECMO. Results During the study period, 510 hospitals performed 29,929 ECMO runs (12,572 vvECMO, 11,504 vaECMO, 1993 pECLA) with an increase over time. Mortality ranged between 58% and 66% for vaECMO cases and 66% and 53% for vvECMO cases. 304 (61%) hospitals performed only one ECMO per year. 78%% of all ECMO runs were performed in centres with more than 20 cases per year and more than half of all ECMO runs were performed in hospitals with >1.000 beds. Mortality for vv and vaECMO was highest in very small hospitals (< 200 beds; 70%; 74%) and very large hospitals (>1000 beds; 60%; 62%). Conclusions Use of ECMO is still increasing and a substantial proportion of hospitals performs very few ECMO runs. Small hospitals had a significantly higher mortality, but dependence on hospital size and ECMO mortality was irregular.

Type 2 Diabetes and all-cause mortality among Spanish women with breast cancer

Purpose To explore the effect of type 2 diabetes mellitus (T2DM) on the risk of death among women with breast cancer (BC). Methods A survival analysis was conducted among a cohort of women diagnosed with BC between 2006 and 2012 in Spain (n = 4,493). Biopsy or surgery confirmed BC cases were identified through the state population-based cancer registry with information on patients’ characteristics and vital status. Physician-diagnosed T2DM was confirmed based on primary health care clinical history. Cox regression analyses were used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for all-cause death. Analyses were adjusted for age, hospital size, several clinical characteristics (including BC stage and histology, among others) and treatment modalities. Results Among the 4,493 BC women, 388 (8.6%) had coexisting T2DM. Overall, 1,299 (28.9%) BC women died during the completion of the follow-up and 785 (17.5%) did so during the first five years after BC diagnosis, resulting in a five-year survival rate of 82.5%. The death rate was higher in women with T2DM (43.8% died during whole period and 26.0% during the first five years) when compared with women without T2DM (27.5% and 16.7%, respectively). Accordingly, all-cause mortality was higher in women with T2DM (aHR: 1.22; 95% CI 1.03–1.44), especially if T2DM was diagnosed before BC (aHR:1.24; 95% CI 1.03–1.50) and in women with BC diagnosed before 50 years (aHR: 2.38; 95% CI 1.04–5.48). Conclusions T2DM was associated with higher all-cause mortality among Spanish women with BC, particularly when the T2DM diagnosis was prior to the BC.

Efficiency and Productivity of Public Hospitals in Serbia Using DEA-Malmquist Model and Tobit Regression Model, 2015–2019

Improving productivity within health systems using limited resources is a matter of great concern. The objectives of the paper were to evaluate the productivity, efficiency, and impact of environmental factors on efficiency in Serbian hospitals from 2015–2019. Data envelopment analysis, Malmquist index and Tobit regression were applied to hospital data from this period, and public hospitals in Serbia exhibited a great variation regarding their capacity and performance. Between five and eight hospitals ran efficiently from 2015 to 2019, and the productivity of public hospitals increased whereas technical efficiency decreased in the same period. Tobit regression indicated that the proportion of elderly patients and small hospital size (below 200 beds) had a negative correlation with technical efficiency, while large hospital size (between 400 and 600 beds), the ratio of outpatient episodes to inpatient days, bed turnover rate and the bed occupation rate had a positive correlation with technical efficiency. Serbian public hospitals have considerable space for technical efficiency improvement and public action must be taken to improve resource utilization.

Determinants of Electrical and Thermal Energy Consumption in Hospitals According to Climate Zones in Poland

Energy use in hospitals is higher than in other public buildings, so improving energy efficiency in healthcare buildings is a significant challenge in this sector of engineering. For this, it is necessary to know the various determinants of energy consumption. Until now, the main factor affecting energy consumption in healthcare facilities studied in the literature was hospital capacity. However, the commonly used variables connected with hospital size and the number of beds do not take into account the medical activities carried out in these buildings. Assuming that energy consumption in hospitals is multiple and shaped by many factors that overlap, not only on an individual level but also on a higher scale level, this study devises a more integrated approach to its determinants. This study aims to investigate the determinants of electrical energy costs (EEC) and thermal energy costs (TEC) in Polish hospitals with regard to factors related to their size, work intensity and climate zones. The analysis was carried out using financial and resource data from all Polish hospitals for the years 2010–2019. The study used a multivariate backward stepwise regression analysis. In order to use climate as a moderating variable, a sample of Polish hospitals from 16 Polish NUTS 2 was divided into four climate zones. This article provides new empirical evidence on the determinants of electricity consumption in Polish hospitals related to their size and medical activity, taking into account climate zone as a moderating variable. The results of the analysis show that both electricity and heat consumption in hospitals are positively related to the number of doctors, beds and the number of medical operations performed. As expected, larger hospitals seem to use more energy. Moreover, there is regional heterogeneity in energy consumption in hospitals related to the climatic zone in which they operate. The conducted analysis shows that Polish hospitals located in the warmest climatic zone are characterized by higher energy consumption than hospitals in the coldest zone. It especially regards EEC in surgery hospitals. The warmer the climate zones, the higher intensity in terms of the number of surgeries, the higher EEC. In terms of nonsurgical hospitals, the influence of climate zone on EEC was not observed. Knowing the factors influencing energy consumption in hospitals can facilitate the correct adoption of an energy-saving strategy in the health sector, which is a reasonable response to climate change and supports a healthy and sustainable future.

Characterizing Firearms-Related Injuries and Craniofacial Fractures: A TQIP Study

Background: Interest in firearm injuries (FAIs), from medical and public health perspectives continues to grow. Few studies have analyzed the relationship of FAIs, craniofacial fractures, and traumatic brain injuries (TBIs). Methods: FAIs were isolated from national data from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) 2014 to 2016 using external cause encodings. Pertinent demographic, injury, and hospital characteristics were extracted to characterize trends and statistically significant outcomes. Results: Thirty-two thousand eight hundred ninety-three (out of 829 805 cases) FAIs were captured, with a majority of patients being male and non-Hispanic/Latino Black. Multivariate linear regression revealed that race/ethnicity, age, hospital size, hospital region, intent of injury, and ISS significantly contributed to risk of mortality, increased hospital length of stay (LOS), and intensive care unit (ICU) duration. Five thousand nine hundred ten (18.0%) FAIs had at least 1 craniofacial fracture, and among these 75.1% (4441) incurred a traumatic brain injury (TBI). Mortality rate among patients with craniofacial FAI was 43.8% (2586/5910), compared to 9.7% (2618/26 983) without. Delayed surgical repair significantly increased hospital LOS ( P < .01), but not mortality ( P = .09). Conclusion: FAIs with craniofacial injury have significantly higher mortality rates than those without craniofacial injury. FAI-associated craniofacial injuries are frequently associated with TBI which is associated with significant morbidity and mortality. Such findings pose important public health and economic implications.

Adoption of large-scale medical equipment: the impact of competition in the German inpatient sector

The availability of large-scale medical equipment such as computed tomography (CT), magnet resonance imaging (MRI) and positron emission tomography (PET) scanners has increased rapidly worldwide over the last decades. Among OECD countries, Germany ranks high according to the number of imaging technologies and their applications per inhabitant. In contrast to other countries, there is no active governmental planning of large-scale medical equipment. We therefore investigated whether and how the adoption and distribution of CT, MRI and PET scanners in the German inpatient sector is subject to competition. Using a linear-probability model, we additionally examined the impact of regional, hospital- and population-based factors. In summary, our results indicate that the adoption rate by hospital sites decreases with the number of other sites being already equipped with the respective device and their proximity. However, the effect presumably depends on the technologies’ stage within the diffusion process. No influence regarding the amount of state subsidies could be identified. Furthermore, hospital size and university status strongly affect the adoption.

Disparities of Palliative Care Utilization in End-of-Life Hospitalized Patients with Leukemia: An Analysis of National Inpatient Sample Database

Background: Early palliative care (PC) encounter has been shown to improve the quality of end-of-life (EOL) care. There is a significant increased in the PC utility of leukemia patients in the past decade. We aim to investigate the use of PC service in hospitalized patients with leukemia and other malignancies at the end of their life. Methods: This is a retrospective study of National Inpatient Sample (NIS) with data year 2016-2018. The cohort of interest was adult patients (age at least 18) who had been hospitalized for at least three days and passed away. International Classification of Diseases, 10th Revision was used to identify patients with leukemia (myeloid, lymphoid and other types), other malignancies, comorbidities, PC encounters, and procedures. Primary outcome was PC encounter. PC-associated factors were analyzed with multivariate logistic regression. Statistical analysis was performed with SAS and R. Results: Among 404,011 hospitalized patients who passed away, a total of 254,431 patients stayed in the hospital for at least three days. There were 5,819 (lymphoid: 2,177; myeloid: 2,848; other: 794) and 56,270 patients had leukemia and other malignancies, respectively. 51.4% leukemia, 57.4% other malignancies and 46.2% non-cancer patients had PC encounter. The PC use significantly increased in all subgroups from 2016 to 2018 (p &lt; 0.0001). The PC utility of leukemia patients improved from 47.4% in 2016 to 55.4% in 2018. Compared to patients with other malignancies, leukemia patients had higher portion of mechanical ventilation use and cardiopulmonary resuscitation (CPR) prior to their death (31.6% vs 40.0%, p &lt; 0.005). The PC utility was significantly higher in other malignancies group (adjusted odds ratio [aOR]: 1.37, p &lt; 0.0001) and lower in non-cancer group (aOR: 0.85, p &lt; 0.0001). Advanced age, female, Medicaid, private insurance, self-pay, higher income, larger hospital size, urban hospital, Midwest and West Region year of 2017 and 2018 were also associated with increased PC utility and African American, Hispanic, Asian or Pacific Islander, South region were associated with lower odds of receiving PC (Figure 1). Among leukemia patients, myeloid leukemia group had higher odds of PC encounter than lymphoid group (aOR: 1.28, p &lt; 0.0001). African American, Hispanic, lower income, and smaller hospital were associated with significantly lower PC consult in leukemia patients. Conclusion: There was an encouraging trend of increased PC consult between 2016 to 2018. Nevertheless, the PC utility was still lower among EOL hospitalized patients with leukemia than with other malignancies. Racial, socioeconomic, and hospital resource disparities were significant limiting factors of PC accessibility. Further systemic intervention and investigation are required to improve the disparities of PC utilization in leukemia patients. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

860. HIV Post-exposure Prophylaxis Availability at Small and Critical Access Hospitals in the Western Region

Background Post-exposure prophylaxis (PEP) is essential to minimize the risk of human immunodeficiency virus (HIV) acquisition following an occupational or nonoccupational exposure to potentially infectious body fluids. PEP is most effective when initiated as soon as possible after HIV exposure. Patients in rural areas may rely on small (&lt; 50 beds) and critical access (&lt; 25 beds) hospitals for access to PEP – especially after-hours and on holidays, when outpatient pharmacies are typically closed. However, PEP medications are costly to maintain on a hospital formulary due to unpredictable use and expiration. We hypothesized that PEP availability may be variable and limited at such hospitals. Methods The University of Washington Tele-Antimicrobial Stewardship Program (UW-TASP) is comprised of 68 hospitals in Washington, Oregon, Arizona, Idaho, and Utah, most of which are rural and critical access. In August 2020, we surveyed UW-TASP participating hospitals and a convenience sample of other networked rural hospitals in Western states using REDCap, a HIPAA-compliant, electronic data management program. Respondents reported all antimicrobials on their hospital formulary and their hospital size. Data were reviewed by physicians and pharmacists trained in infectious diseases. Preferred PEP regimens, defined by the CDC, for adults and adolescents ≥ 13 years, included combination tenofovir disoproxil fumarate-emtricitabine (TDF/FTC) and either raltegravir (RAL) or dolutegravir (DTG). Results Responses from 49 hospitals were received. Six were excluded – one was incomplete and five were excluded due to hospital size ( &gt; 50 beds) (Table 1). The majority of hospitals (40/43, 93.0%) were critical access. Half of the hospitals’ formularies (22/43, 51.2%) contained a preferred PEP regimen. One hospital reported a non-preferred regimen. Most hospitals with a preferred PEP regimen on formulary (18/22, 86.3%) offered TDF/FTC + RAL, and the remainder (4/22, 18.2%) offered TDF/FTC + DTG. Conclusion Many small and critical access hospital formularies do not include antiretroviral agents needed for HIV PEP. Improving urgent access to these critical medications in rural communities is an opportunity for HIV prevention. Disclosures Jehan Budak, MD, Nothing to disclose Chloe Bryson-Cahn, MD, Alaska Airlines (Other Financial or Material Support, Co-Medical Director, position is through the University of Washington)

133. A Review of Antimicrobial Formularies at Rural Hospitals: Stewardship Opportunities Abound

Background Management of a hospital’s antimicrobial formulary is an important aspect of antimicrobial stewardship and cost containment strategies. Ensuring that essential medications for clinical care are available and excluding therapeutic duplicates and unnecessary antimicrobials is time and resource intensive. Comparisons of antimicrobial formularies across multiple rural hospitals have not been evaluated in the literature. We hypothesized that a comprehensive formulary evaluation would reveal important opportunities for antimicrobial stewardship efforts and could help smaller hospitals optimize available medications. Methods The University of Washington Tele-Antimicrobial Stewardship Program (UW-TASP) is comprised of 68 hospitals of varying sizes, most of which are rural and critical access, in Washington, Oregon, Arizona, Idaho, and Utah. We surveyed UW-TASP participating hospitals and other networked rural hospitals in multiple Western states using REDCap, a HIPAA-compliant, electronic data management program. Respondents reported which antimicrobials are on their hospital formulary as well as basic information about hospital size and inpatient units. Data were reviewed by a panel of infectious diseases trained physicians and pharmacists at UW-TASP. Results Surveys from 49 hospitals were received; two were excluded from the data analysis (Table 1) – one submission was incomplete, and one was a large inpatient psychiatric hospital. Select antimicrobials and proportion of hospitals carrying these agents is shown in Table 2. Several antimicrobials are on the formulary at all hospitals, regardless of size. In some critical access hospitals (&lt; 25 beds), empiric first-line bacterial meningitis and viral encephalitis coverage (Table 3) was lacking. Six hospitals (12.7%) lacked ampicillin for Listeria coverage and only one had a suitable alternative agent (meropenem). Seven hospitals (14.9%) lacked intravenous acyclovir, although three had oral valacyclovir. Formulary inclusion of agents for multi-drug resistant organisms was rare. Conclusion In critical access hospitals in the Western USA, lack of essential empiric antimicrobials may be more of a concern than inclusion of agents with unnecessarily broad spectra. Disclosures Chloe Bryson-Cahn, MD, Alaska Airlines (Other Financial or Material Support, Co-Medical Director, position is through the University of Washington)