Burden of Chronic and Acute Conditions and Symptoms in People With Epilepsy

Objective:People with epilepsy, one-third of whom in the US are on Medicaid, experience a wide range of chronic and physical comorbidities that influence their care and outcomes. In this study, we examine the burden and racial/ethnic disparities of chronic and acute conditions, injuries, and symptoms in a large and diverse group of people with epilepsy on Medicaid.Methods:Using 5 years of Medicaid claims data we identified adult people with epilepsy and used all available claims and diagnoses to identify each person’s Clinical Classification Codes groups diagnosed during the study period. Using association rule mining we identified the top combinations of conditions and stratified these by race/ethnicity to identify potential prevalence disparities. Additionally, we examined the top combinations of conditions in high utilizers – that is individuals in the top quartile of hospitalizations and emergency department visits.Results:Among 81,963 patients the most common conditions were: anxiety and mood disorders (46.5%), hypertension (36.9%), back problems (35.2%), developmental disorders (31.6%), and headache (29.5%). When examining combinations of conditions, anxiety and mood disorders continued to have an outsized prevalence – appearing in nearly every combination. There were notable disparities in disease burden, with American Indians and Alaskan Natives having a substantially higher prevalence of developmental disabilities, while Black individuals had a higher prevalence of hypertension. These disparities persisted to the higher-order combinations that included these conditions. High utilizers had a much higher disease burden, with 75.8% having an anxiety or mood disorder, as well as a higher burden of injuries.Significance:This study shows a high prevalence of psychiatric and physical conditions and identifies racial and ethnic disparities affecting people with epilepsy. Targeting interventions to consider the comorbidities, race and ethnicity has potential to improve clinical care and reduce disparities.

Characteristics of sickle cell patients with frequent emergency department visits and hospitalizations

Vaso-occlusive episodes (VOEs) are a hallmark of sickle cell disease (SCD), and account for >90% of health care encounters for this patient population. The Cooperative Study of Sickle Cell Disease, a large study enrolling >3000 patients, showed that the majority of SCD patients (80%) experienced 0–3 major pain crises/year. Only a small minority (~5%) experienced ≥6 VOEs/year. Our study sought to further understand this difference in VOE frequency between SCD patients. We analyzed 25 patients (13M/12F, mean age of 28.8) with ≥6 ED visits or hospitalizations/year (high utilizers), and compared these with 9 patients (6M/3F, mean age of 37.6) who had ≤2 ED visits or hospitalizations/year (low utilizers). All subjects were given a demographic survey along with questionnaires for depression, anxiety, and Health Locus of Control. Each subject then underwent quantitative sensory testing (QST) with three different modalities: pressure pain sensitivity, heat and cold sensitivity, and Von Frey monofilament testing. Laboratory and clinical data were collected through subjects’ medical records. CBC and chemistry analysis showed high utilizers had higher WBC (p<0.01), ANC (p<0.01), total bilirubin (p = 0.02), and lower MCV (p = 0.03). Opioid use (morphine equivalents) over the past 6 months was significantly higher in the high utilizer group (12125.7 mg vs 2423.1 mg, p = 0.005). QST results showed lower pressure pain threshold at the ulna (224.4 KPa vs 338.9 KPa, p = 0.04) in the high utilizer group. High utilizers also had higher anxiety (9.0 vs 4.6, p = 0.04) and depression scores (10.0 vs 6.0, p = 0.051). While the low utilizer group had higher education levels with more associate and bachelor degrees (p = 0.009), there was no difference in income or employment. These data show that many biological and psychosocial factors contribute to high health care utilization in SCD. A multi-disciplinary and multi-faceted approach will be required to address this complex problem.

Mental health and policing: Picking up the pieces in a broken system

A key theme of this article is the need to view the intersection of public safety and public health through a new lens to break down the traditional information silos of the many agencies that serve vulnerable populations and the impact of inadequate community-based mental health services that contribute to the increasing number of calls to police in responding to people in or approaching a mental health crisis. The manifestation of this crisis in the community is that the police are too often the first port in the storm. This article suggests the system is broken and needs fixing. Implementing a population health approach to identifying the high utilizers in the community and building a case for sustained funding, partnerships, resources, and accountability together with data sharing agreements, community partners and police collaboratively design and evaluate outcome approaches aimed at prevention and recovery to minimize contact with the police.

Decreased Hospitalizations and Improved Health-Related Outcomes Using Client-Centered Therapy in Adults with Sickle Cell Disease with High Health Care Utilization

Background:Sickle cell disease (SCD) is a chronic multisystem disorder associated with vaso-occlusive pain and organ damage, leading to substantial morbidity, impaired health-related quality of life, increased health care costs, and a high risk of premature death (Platt el al. N Engl J Med. 1994). SCD complications and pain episodes accounted for 23% of statewide admissions, mainly by a small group of high utilizers. (Woods et al. Public Health Rep, 1997). Adults with SCD have a high rate of depression, 35% compared to 6.7% in the general adult population (Adam, Flahiff, Kamble, et al. 2017). Chronic persistent pain occurs in more than a third of adults with SCD. Opioid analgesics, the mainstay for the management of acute and chronic pain, often results in opiate use disorder (Ehrentraut et al. J Pediatr Psychol. 2014). Current clinical approaches to address depressive symptoms in SCD have not been effective due to the gaps in care and barriers to access healthcare resources. Client-centered (or person-centered) therapy, is a non-directive approach to counseling that incorporates the concepts of unconditional positive regard, empathetic understanding, genuine affect, and culturally responsive care to improve psychosocial outcomes (Meyer & Zane, 2018). We sought to address these perceived gaps in care using client-centered therapy to improve patient related health outcomes in a cohort of adult patient who were high utilizers. Methods:The study sample comprised 9 patients with SCD (HbSS and SC), ages 23-42, who followed with the adult SCD Clinic at Vanderbilt University Medical Center in Nashville, TN. This cohort of patients was selected as they accounted for the highest health care utilization in our adult program. Demographics and baseline clinic data were obtained on each participant, including pre- and post-measures for hospitalizations, oral morphine equivalent (OME), PHQ-9 to measure depressive symptoms, and the Working Alliance Inventory (WAI), to measure the effectiveness of the client-centered approach to therapy (based on consensus of goals, confidence in and commitment to helping relationship, and mutual trust). Our approach to evaluations is depicted in Figure. Exclusion criteria included current diagnosis of psychosis or a comorbid disorder with psychosis as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition); active suicidal/homicidal ideation, and unwillingness to participate in counseling. Patients were expected to attend 7 individual sessions for 60 minutes each with a trained mental health clinician. Clinical and laboratory data was obtained through electronic medical record under an IRB approved protocol. Results:In our sample, 5/9 (56%) of our patients were male and they were all African Americans. Eight out of 9 participants had HbSS and 1 had HbSC. The median age of all participants was 30 years. The participants completed a combined total of 64 sessions over an average of 6.7 months. All participants completed an average of 7 sessions each. The average number of hospitalizations pre-intervention per participant was 3 and decreased to 1 post-intervention. The pre and post OME totals for 6/9 participants remained stable. One participant (#8) had a 50% decrease in OME, and two participants (#2, #3) had an increase in total OME post-intervention associated with pregnancy-related complications. Pre-intervention, 69% of participants identified mild to moderate severity in depressive symptoms. The total PHQ-9 scores decreased post-intervention by 3 points, or by 4.4%. The WAI average post-intervention depicts an average of 87.5% of participants identified a strong working alliance with their therapist (Table). Conclusion:Our pilot study shows that client-centered therapy is a safe and effective approach to address age-dependent chronic health challenges of adults with SCD. Client-centered therapy decreased hospitalization rates and PHQ-9 scores for our high utilizers. Though there was not a statistically significant decrease in participants' OME, 67% of the sample remained stable, without an OME increase during the intervention period. Future research and longer-term studies are needed on utilizing this approach to address coping mechanisms, baseline stress levels, and overall quality of life in a larger cohort of adults with SCD. Disclosures No relevant conflicts of interest to declare.

Impact of an Infusion Center on the Utilization of Hospital Based Care in Sickle Cell Disease

Background: Sickle cell disease (SCD) consists of a group of hemoglobinopathies inherited in an autosomal recessive pattern whereby a single point mutation results in the formation of a hemoglobin protein with altered structure. Many of the complications of SCD and their end organ manifestations are the result of a vaso-occlusive process. These include acute chest syndrome, dactylitis, myocardial infarction, stroke, venous thromboemboli, avascular necrosis, and acute vaso-occlusive episodes (VOEs). VOEs are the most common reason for a patient with SCD to seek medical attention. This care is often provided at an emergency department (ED). It has been well documented that the management of VOEs are often delayed and fail to follow published guidelines. Numerous efforts have been undertaken to ensure appropriate and timely analgesic administration to patients with SCD who are experiencing a VOE. One such intervention is the creation of an infusion center (IC) that has the capability to administer parenteral opioids while avoiding the delays associated with an ED visit. Objectives: This study aims to evaluate the impact of a dedicated IC that was established for the treatment of SCD VOEs. The goal of the IC is to provide timely and appropriate pain management in an effort to reduce ED visits and hospital admissions related to treatment of VOEs in patients with SCD. The IC was available to adult patients with SCD who regularly sought care at our hospital and who did not have a care plan that excluded the administration of parenteral opioids. Methods: This is an observational, retrospective study comparing the rates of hospital utilization before and after the opening of a dedicated IC for patients treated for SCD VOE at a single, urban medical center that regularly provides care for approximately 150 adult patients with SCD. We compared the rates of ED visits, hospital admissions, and length of stay for six months prior and four months following the opening of the IC. Hospital utilization was standardized before and after the intervention using 30-day rates. Additionally, opioid usage, measured in Morphine Equivalent Dose (MED) was compared between the ED and the IC. Results: A total of 12 patients (Table 1) utilized the IC during the 4 months after its opening (6/20/19 - 10/16/19). During this time there were 92 total visits to the IC. Four patients were noted to be high utilizers accounting for 77 (83.7%) of the 92 visits (median = 20 visits, range 12 - 25). The other 8 patients were low utilizers and accounted for 15 (16.3%) of the visits (median = 2, range 1 - 4). Following implementation of the IC, there was found to be a statistically significant decrease in ED visits (pre- = 3.97/30d vs post- = 2.40/30d; p = 0.04) (Table 2, Fig. 1). No significant difference was found in hospital admissions (pre- = 1.47/30d vs post- = 1.17/30d; p = 0.18) or inpatient days (pre- = 6.47/30d vs post- = 5.47/30d; p = 0.23). The total number of acute care visits (sum of ED and IC visits) was found to increase after the opening of the IC, although the change was not statistically significant (pre- = 3.97/30d vs post- = 5.47/30d; p = 0.07). The change in acute care visits was largely driven by an increase in visits from the high utilizers (pre- = 2.00/30d vs post- = 3.53/30d; p = 0.05). In terms of parenteral opioid administration, there was a statistically significant decrease in amount of opioids given in the IC compared to the ED (ED = 251.64 MED vs IC = 177.17 MED; p = 0.04), although this was only seen in the low utilizer group (Table 3, Fig. 2). There was no significant difference in opioid doses received for the high utilizers (ED = 256.31 MED vs IC = 272.12 MED; p = 0.24) and for the group as a whole (ED = 253.34 MED vs IC = 208.84 MED; p = 0.10). Conclusion: The introduction of an IC for the management of SCD VOE led to a significant decrease ED visits but also led to an increase in overall acute care visits, although this was not statistically significant. This increase was largely driven by a subset of this population considered high utilizers. Additionally, the use of the IC was not associated with a decrease in the total amount of parenteral opioids that were administered. However, for the low utilizer group there was a decrease in parenteral opioid administration. The IC did not reduce admissions and duration of hospitalization in this population. Overall, the IC had variable success and further refinement of how it is used should be undertaken to ensure quality care for patients with SCD. Disclosures No relevant conflicts of interest to declare.

1562. Reduction in Healthcare Utilization and Overdose after Skin and Soft Tissue Infections for Injection Drug Users through Addiction Medicine Consultation

Background Healthcare encounters for skin and soft tissue infections (SSTIs) due to injection drug use (IDU) may provide opportunities for interventions to improve outcomes. We explored factors that may impact reduction of healthcare utilization and modify other complications of substance use disorder after an IDU-related SSTI. Methods We conducted a retrospective cohort chart review for 305 patients with IDU-related SSTIs between 10/1/2015 and 6/1/2019 to examine demographic, clinical and healthcare utilization data one year before and after the SSTI encounter. Patients were categorized as a low utilizer if they had &lt; 3 emergency department encounters and as a high utilizer if they had ≥3 encounters in the one-year period before or after the SSTI. For patients that changed utilization categories from the pre- to post-SSTI period, we analyzed demographic and clinical differences using Chi Square tests. We performed a secondary analysis using a Wilcoxon test to examine the relationship between receipt of an addiction consult and change in number of overdoses after SSTI. Results 131 patients were low utilizers at baseline and 174 were high utilizers. Patients who transitioned from low to high utilization (64 patients) were significantly less likely to have received an addiction consult, 16 (25%), than patients who transitioned from high to low utilization, 15 (48%), p=0.03. However, high utilizers were significantly more likely to remain a high utilizer (p&lt; 0.0001) with no variable predictive of transition to low utilization including addiction consultation, homelessness, insurance type, or treatment with medications for opioid use disorder. Patients who were low utilizers at baseline were more likely to remain low utilizers if they were not homeless, p=0.01. Of the entire sample, 96.2% (p&lt; 0.0001) of those admitted obtained an addiction consult, which significantly reduced rates of overdose in the following year (p=0.0014) for 223 patients for which we had overdose data. Conclusion Patients with IDU-related SSTIs who do not receive an addiction consult are more likely to cross from low to high utilization after the event. Preferentially targeting this population for addiction consultation can significantly improve outcomes. Disclosures All Authors: No reported disclosures

Cross-Sectional Study of Homeless High Service Utilizers in Los Angeles County Jails: Race, Marginalization and Opportunities for Diversion

Objectives: To describe the demographic, legal, and clinical characteristics of a cross-section of incarcerated homeless individuals with the highest utilization of Los Angeles (LA) County public services in order to increase opportunities for focused jail diversion.Methods: The “5% list” (N=5,905 in Febru­ary 2018), LA County’s list of homeless individuals with the highest 5% utilization of public services, was cross-matched with the total jail population to obtain a sample of 333 homeless high-utilizing individuals. This sample was compared with the overall jail population (N=17,121) from publicly avail­able aggregate data by Chi-square testing.Results: 84% of the high-utilizing sample were male, 38% Black, 37% Hispanic, 21% White. 67% were prescribed psychiatric medication. Compared with the overall jail population, the sample was significantly older, with a greater proportion of Black and White persons, and a lesser propor­tion of Hispanic individuals relative to the overall jail population. A significantly greater proportion of high-utilizing individuals faced misdemeanor charges.Conclusions: These data highlight the compounding effects of homelessness, race, and mental illness on carceral and social vulnerability. Findings suggest homeless high utilizers in jail with mental illness are likely to benefit from court-based diversion efforts aimed at housing and treatment. Ethn Dis. 2020;30(3):501-508. doi:10.18865/ed.30.3.501