National Hospital Care Survey Demonstration Projects: Examination of Inpatient Hospitalization and Risk of Mortality Among Patients Diagnosed With Pneumonia

NHSR 167

Predicting Medical Fees for Hospitalized Inpatients and the Determination of Inflection Point

Background: Taiwan’s Bureau of National Health Insurance (BNHI) implemented an inpatient DRG payment system scheduled for January 2008. Many hospital managers urgently invent initiatives to decrease the impacts of DRGs. Predicting medical fees for hospitalized inpatients every day and the corresponding inflection points (IPs) are required for investigations. The aims of this study include (1) verifying the efficacy of the exponential growth model on accumulative publications of mobile health research between 1997 and 2016 in the literature; (2) building the model of predicting medical fees for hospitalized inpatients and determining the inflection points; and (3) demonstrating visualizations of the prediction model online in use for hospital physicians.Methods: An exponential growth model was applied to determine the IP and predict the medical fees to help physicians contain the medical fees of a specific patient during hospitalization. The IP is equal to the item difficulty proven using the differential equation in calculus. An online visual display of the medically contained and predicted inpatient hospitalization was demonstrated in this study.Results: We observed (1) a model accuracy (R2 = 0.99) higher than that (R2 = 0.98) in the literature based on identical data; (2) 231 samples of medical fees for inpatients in the study module with a length of days between 6 and 20 and an IPS falling in the range between 1 and 10 (Q1=0.98, Q3=1.00); and (3) online visualization demonstration of medical fees predicted for hospital inpatients and IP determination on ogive curves.Conclusion: The exponential growth model can be applied to a clinical setting to help physicians consecutively predict medical fees for hospitalized inpatients and upgrade the level of hospital management in the future.

Making complex decisions in uncertain times: experiences of Dutch GPs as gatekeepers regarding hospital referrals during COVID-19—a qualitative study

Background General practitioners often act as gatekeeper, authorizing patients’ access to hospital care. This gatekeeping role became even more important during the current COVID-19 crisis as uncertainties regarding COVID-19 made estimating the desirability of hospital referrals (for outpatient or inpatient hospitalization) complex, both for COVID and non-COVID suspected patients. This study explored Dutch general practitioners’ experiences and ethical dilemmas faced in decision making about hospital referrals in times of the COVID-19 pandemic. Methods Semi-structured interviews with Dutch general practitioners working in the Netherlands were conducted. Participants were recruited via purposive sampling. Thematic analysis was conducted using content coding. Results Fifteen interviews were conducted, identifying four themes: one overarching regarding (1) COVID-19 uncertainties, and three themes about experienced ethical dilemmas: (2) the patients’ self-determination vs. the general practitioners’ paternalism, (3) the general practitioners’ duty of care vs. the general practitioners’ autonomy rights, (4) the general practitioners’ duty of care vs. adequate care provision. Conclusions Lack of knowledge about COVID-19, risks to infect loved ones, scarcity of hospital beds and loneliness of patients during hospital admission were central in dilemmas experienced. When developing guidelines for future crises, this should be taken into account.

Healthcare Resource Utilization and Costs in US Patients with Newly Diagnosed Acute Myeloid Leukemia Treated with Intensive Induction Chemotherapy

INTRODUCTION: Acute myeloid leukemia (AML) is a heterogeneous hematologic malignancy. In the United States (US) in 2020, the incidence of AML was 4.3/100,000, with a death rate of ~2.8 per 100,000. Following diagnosis, for patients who are fit for high-dose therapy, standard of care consists of initial intensive remission-inducing chemotherapy followed by post-remission therapy comprising consolidation chemotherapy alone, hematopoietic stem cell transplantation (HSCT) alone, or consolidation chemotherapy followed by HSCT. Despite an initial response to treatment, most patients with AML progress, and relapse is common. Relapse in AML is associated with poor prognosis, substantial healthcare resource utilization (HCRU), and a cost burden. Maintenance therapy with newer agents may delay relapse and prolong survival. Understanding HCRU and costs of newly diagnosed AML may inform clinicians, policy makers, and payers on the burden of AML and the potential clinical and economic benefits of novel therapies. This retrospective study describes HCRU and costs for patients with newly diagnosed AML receiving intensive induction chemotherapy in the US. METHODS: The Premier Healthcare Database was used to identify patients aged ≥18 years with an inpatient hospitalization or hospital-based outpatient visit (01/01/2016-03/31/2019), an AML diagnosis (ICD-10-CM diagnosis codes: C92.00, C92.40, C92.50, C92.60, C92.A0), who received CPX-351 or 7+3 treatments, and had ≤280 days from the end of first induction treatment to remission. Patients with prior AML diagnosis or those receiving other treatments were excluded. Index date was the admission date for the first hospitalization or the first hospital-based outpatient visit with an AML diagnosis. Patients were followed until death, relapse or last known follow-up, whichever was first. Unadjusted descriptive analyses were performed for patient demographics, baseline clinical characteristics, outpatient days, inpatient hospitalizations, intensive care unit (ICU) admissions, and costs. RESULTS: Overall, 642 patients who received induction chemotherapy for newly diagnosed AML were identified. Mean (median) patient age was 53.7 (56.0) years, and 53.1% of patients were male. Patients had commercial (47.2%), Medicare (26.8%), Medicaid (17.6%), or other (8.4%) insurance. Mean (SD) Charlson Comorbidity Index was 3.5 (2.2), and the most common comorbidities were diabetes (20.3%), chronic pulmonary disease (15.4%), and congestive heart failure (9.4%). Most frequent adverse events were pyrexia (47.2%), neutropenia (39.9%), sepsis (28.0%), pneumonia (24.3%), and fungal infection (17.9%). Median (interquartile range [IQR]) time from the end of first induction chemotherapy to remission was 58 (40-90) days. Median (IQR) time from remission to relapse was 274 (141-389) days. A total of 385 (60.0%) patients had outpatient service days at a Premier facility; median (IQR) number of outpatient service days per patient was 3 (1-6), outpatient hospital cost per visit was $1,083 ($481-$2,189), and total outpatient hospital cost was $2,904 ($1,054-$7,217). All patients had an inpatient hospitalization; median (IQR) number of inpatient hospitalizations per patient was 2 (2-3), length of stay (LOS) per inpatient hospitalization was 16 (13-21) days, cost per inpatient hospitalization was $34,558 ($25,419-$49,460), and total inpatient hospital cost was $83,440 ($63,067-$113,985). A total of 144 (22.4%) patients had an ICU admission; median (IQR) number of ICU admissions per patient was 1 (1-1), LOS per ICU admission was 3 (2-8) days, cost per ICU visit was $15,771 ($7,209-$27,564), and ICU cost was $16,550 ($7,368-$36,968). CONCLUSIONS: In the US, healthcare costs for patients with newly diagnosed AML who receive induction chemotherapy are considerable, primarily due to high HCRU and lengthy inpatient stays. Patient response to induction therapy and duration of remission may also contribute to HCRU and costs. More tolerable therapies that improve remission rate and duration, and/or reduce hospitalization rates, may alleviate the economic burden of AML. Disclosures Huggar: Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Knoth: Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Copher: Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Cao: Premier, Inc.: Current Employment; BeiGene, Ltd.: Consultancy. Lipkin: Premier, Inc.: Current Employment. McBride: Bristol Myers Squibb: Current Employment. LeBlanc: Amgen: Consultancy, Other: travel; BMS/Celgene: Consultancy, Honoraria, Other: Travel fees, Research Funding, Speakers Bureau; Flatiron: Consultancy, Other: Advisory board; Astellas: Consultancy, Honoraria, Other: Advisory board; Duke University: Research Funding; American Cancer Society: Research Funding; Helsinn: Consultancy, Research Funding; AstraZeneca: Consultancy, Honoraria, Other: Advisory board, Research Funding; Heron: Consultancy, Honoraria, Other: advisory board; Agios: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; Pfizer: Consultancy, Other: Advisory Board; CareVive: Consultancy, Other, Research Funding; Seattle Genetics: Consultancy, Other: Advisory board, Research Funding; Jazz Pharmaceuticals: Research Funding; Otsuka: Consultancy, Honoraria, Other; Daiichi-Sankyo: Consultancy, Honoraria, Other: Advisory board; AbbVie: Consultancy, Honoraria, Other: Advisory board; Travel fees, Speakers Bureau; UpToDate: Patents & Royalties; NINR/NIH: Research Funding.

Initiation of buprenorphine for opioid use disorder in the hospital setting: Practice models, challenges, and legal considerations

Purpose To provide health-system pharmacists with published examples of strategies utilized to offer buprenorphine to inpatients with opioid use disorder (OUD) along with information on challenges and legal considerations. Summary Hospitals and emergency departments (EDs) are a constant source of healthcare for patients with OUD. As a result, hospital practitioners can screen, diagnose, begin treatment, and facilitate transfer of care to the outpatient setting. Offering sublingual buprenorphine in the hospital can bridge the gap before outpatient care is established. Multiple studies have shown that initiating treatment in the ED or during inpatient hospitalization results in 47% to 74% of patients utilizing medication-assisted treatment at day 30 of follow-up, statistically superior to the rates achieved with brief interventions or referral alone. Moreover, initiating buprenorphine treatment in the ED has been shown to decrease healthcare costs. Despite the benefits of offering buprenorphine in the inpatient setting, several challenges must be solved by hospital administration, such as achieving clinician readiness to prescribe buprenorphine, developing relationships with outpatient providers of buprenorphine, and creating an efficient workflow. Treatment of OUD with buprenorphine is heavily regulated on the federal level. Pharmacists can participate in the development of these programs and ensure compliance with applicable laws. Conclusion As health systems continue to care for patients with OUD, starting buprenorphine in the inpatient setting can improve the transition to outpatient treatment. Several institutions have developed programs with positive results. With an understanding of the typical barriers and relevant laws when initiating buprenorphine in the hospital setting, health-system pharmacists can assist in the development and operation of these initiatives.

Risk of Hospitalization Associated With Different Constellations of Home & Community Based Services

Background:Identify the association between specific combinations of home and community-based services (HCBS) and risk of acute hospitalization. Methods:Data for this study came from Pennsylvania Medicaid claims, enrollment files, enrollee evaluations, and Medicare and Medicaid hospitalization records. This analysis compared risk of inpatient hospitalization across an entire state Medicaid population of community dwelling elderly individuals receiving HCBS. Twelve constellations of HCBS were identified, each composed of different services. Using logistic regression, we derived predicted probabilities of experiencing hospitalization for people in each constellation. This was secondary data analysis conducted outside of a hospital. This study used observational data. There was no randomization.Results:The highest risk of hospitalization, 15.1%, was associated with use of home delivered meals and low levels of PAS. The lowest risk of hospitalization, 7.5% was associated with use of adult day care and low levels of PAS. An 11.6% risk of hospitalization was associated with people who had applied to receive HCBS but were deemed ineligible. This risk was higher than all other constellations of HCBS except for the risk associated with using only low levels of PAS (13.9%) and using low levels of PAS and home delivered meals (15.1%). Conclusions: Using medium and high levels of PAS was associated with lower hospitalization risk compared to only low levels of PAS. Offering a higher initial level of PAS upon enrollment in Medicaid could potentially reduce hospitalization risk. People receiving home delivered meals had an elevated hospitalization risk.