The Effect of Hospital Safety Net Status on the Association Between Bundled Payment Participation and Changes in Medical Episode Outcomes

BACKGROUND: Under Medicare’s Bundled Payments for Care Improvement (BPCI) program, hospitals have maintained quality and achieved savings for medical conditions. However, safety net hospitals may perform differently owing to financial constraints and organizational challenges. OBJECTIVE: To evaluate whether hospital safety net status affected the association between bundled payment participation and medical episode outcomes. DESIGN, SETTING, AND PARTICIPANTS: This observational difference-in-differences analysis was conducted in safety net and non–safety net hospitals participating in BPCI for medical episodes (BPCI hospitals) using data from 2011-2016 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease. EXPOSURE(S): Hospital BPCI participation and safety net status. MAIN OUTCOME(S) AND MEASURE(S): The primary outcome was postdischarge spending. Secondary outcomes included quality and post–acute care utilization measures. RESULTS: Our sample consisted of 803 safety net and 2263 non–safety net hospitals. Safety net hospitals were larger and located in areas with more low-income individuals than non–safety net hospitals. Among BPCI hospitals, safety net status was not associated with differential postdischarge spending (adjusted difference-in-differences [aDID], $40; 95% CI, –$254 to $335; P = .79) or quality (mortality, readmissions). However, BPCI safety net hospitals had differentially greater discharge to institutional post–acute care (aDID, 1.06 percentage points; 95% CI, 0.37-1.76; P = .003) and lower discharge home with home health (aDID, –1.15 percentage points; 95% CI, –1.73 to –0.58; P < .001) than BPCI non–safety net hospitals. CONCLUSIONS: Under medical condition bundles, safety net hospitals perform differently from other hospitals in terms of post–acute care utilization, but not spending. Policymakers could support safety net hospitals and consider safety net status when evaluating bundled payment programs.

Quantitative Lung Ultrasonography for the Nephrologist: Applications in Dialysis and Heart Failure

Volume overload and its attendant increase in acute care utilization and cardiovascular morbidity and mortality represents a critical challenge for the practicing nephrologist. This is particularly true among patients with ESKD on HD where pre-dialysis volume overload and intradialytic and postdialytic hypovolemia account for almost a third of all cost for the Medicare dialysis benefit. Quantitative lung ultrasound is a tool for assessing the extent of extravascular lung water which outperforms physical exam and plain chest radiography. B-lines are vertical hyperechoic artifacts present in patients with increased extravascular lung water. B-lines have been shown to decrease dynamically during the hemodialysis treatment in proportion to ultrafiltration volume. Among patients with chronic heart failure, titration of diuretics based on the extent of pulmonary congestion noted on lung ultrasonography has been shown to decrease recurrent acute care utilization. Early data from randomized-controlled trials of lung ultrasound-guided ultrafiltration therapy among patients with ESKD on HD have shown promise for potential reduction in recurrent episodes of decompensated heart failure and cardiovascular events. Ultimately lung ultrasound may predict those who are ultrafiltration tolerant and could be used to decreased acute care utilization and thus cost in this population.

Retrospective Study Evaluating Effect of Voxelotor Treatment on Acute Care Utilization during the Peak of COVID-19

Introduction In sickle cell disease (SCD), the polymerization of deoxygenated HbS fundamentally alters the structure of the erythrocyte, producing the sickle cell that is characteristic of the disease. Clinical manifestations often perceived in patients suffering from SCD include vaso-occlusion, anemia, and hemolysis. Due to these sequelae, patients frequent the emergency room (ER), urgent care clinic, and hospital. Voxelotor, an oral medication approved by the Food and Drug Administration (FDA) in 2019 for the treatment of SCD, directly targets the pathophysiology of SCD by inhibiting deoxygenated HbS polymerization. Results of the Phase III HOPE trial indicate that the drug can increase hemoglobin levels and reduce markers of hemolysis as well as the incidence of worsening anemia in patients with SCD (Vichinsky et al. N Engl J Med 2019). The COVID-19 pandemic has posed several challenges for patients with SCD in 2020. Amid the pandemic, patients continued to seek out acute medical care, including care in the ER, urgent care clinics, and hospital. The aim of this study was to determine whether utilization of acute medical care differed for patients who received voxelotor before and after therapy in 2020. We also evaluated the utilization of healthcare through telemedicine platforms to facilitate access to novel therapies such as voxelotor for patients with SCD. Methods 13 patients (≥18 years of age as of January 1, 2020) with SCD who had begun treatment with voxelotor between January 1, 2020 and December 31, 2020 were included in the initial analysis. Six patients were excluded from final analysis: three discontinued treatment due to side effects, one was noncompliant with treatment, and two were lost to follow-up. Acute care utilization, measured by the number of times each patient visited the ER, urgent care clinic, and hospital was compared for each patient in the period six months prior to their first dose of voxelotor and in the period six months after their last dose of the drug in 2020 using paired t-tests and Wilcoxon matched-pairs signed rank tests. Demographic information and the type of visit at which patients agreed to proceed with voxeletor was recorded for each patient. Simple linear regressions and multiple regressions controlled for covariates, defined as sex, BMI, age, type of insurance coverage, and duration of treatment. Results All seven (100%) patients discussed voxelotor treatment with their provider during a telehealth video visit. In the period before initiating treatment, patients frequented the ER an average of 2.71 (SD=6.75) times. In the six months after their last dose, patients visited the ER less than they had in the period prior to treatment, on average 0.57 (SD=0.79) times. This difference did not achieve statistical significance (p&gt;0.9999). The mean number of visits to the urgent care clinic in the six months before treatment was 2.71 (SD=6.75) compared to 2 (SD=4) in the period after patients' last dose in 2020. This finding was not statistically significant (p&gt;0.9999). Hospitalizations, on average, decreased significantly from 5.14 (SD=2.34) in the six months before starting treatment to 1.57 (SD=0.98) after ending therapy for 2020 (p=0.0015). Covariates did not have an effect on the differences in acute care utilization before treatment and after last treatment in 2020. Conclusions The findings of this study imply that treatment with voxelotor was associated with a decrease in the frequency of hospitalizations for the seven patients analyzed. This finding can potentially be attributed to the efficacy of voxelotor in improving anemia and reducing complications associated with SCD. While the difference between ER visits and urgent care visits before treatment and after the last dose in 2020 did not achieve statistical significance, likely due to small sample size, the data does suggest a reduction in both outcomes. In addition, the observation that all visits in which patient and provider discussed and initiated treatment were virtual support the use of telemedicine technology to improve access to multidisciplinary care and novel therapies for SCD patients. The impact of voxelotor treatment will continue to be assessed in SCD patients at our institution, and more data from clinical encounters will lead to a greater understanding of the efficacy of voxelotor. Figure 1 Figure 1. Disclosures Jain: GBT: Speakers Bureau; Novartis: Speakers Bureau; Sanofi: Other: advisory board; Argenx: Other: advisory board; DOVA: Other: advisory board.

Impact of the COVID-19 Pandemic on Acute Care Visits for Patients with Sickle Cell Disease

Introduction: The COVID-19 pandemic significantly impacted emergency department (ED) and overall hospital utilization, with a substantial decline in non-COVID-19-related medical presentations. In the weeks following the declaration of a national health emergency, ED visits declined by 42%. Patients with sickle cell disease (SCD) are at risk for needing ED-based care and hospitalization due to disease-specific complications. We examined the impact of the COVID-19 pandemic on acute care utilization by patients with SCD at our institution. Methods: We performed a retrospective cohort study at our institution comparing the period of the first "stay at home" order in Baltimore, MD (3/30/2020-6/8/2020) to the same date range in 2019. We included all adult patients with SCD who either presented to the ED or were directly admitted to the hospital. All SCD genotypes were included (HbSS, HbSC, HbSβ +/0 thalassemia). Data collected included presenting symptoms, disposition for ED visits, admission length of stay (LOS), re-admission within 7 days, as well as frequency of sickle cell-specific complications during hospitalization. We collected data regarding the acuity of patients' initial presentation using the emergency severity index (ESI), a five-tiered grading tool utilized by triage nurses to indicate the acuity and resource-intensiveness of a patient's presenting symptoms (1= highest urgency, 5= least urgency). We performed statistical analyses using Pearson's chi square test, Fisher's exact test and the Mann-Whitney U test. Results: During the initial stay at home order in 2020, 77 patients presented to acute care services at our institution, compared to 163 patients during the same dates in 2019, a decrease of &gt; 50%. Statistically significant demographic differences between 2020 and 2019 included gender (53% vs 34% male gender, p = 0.004) and hemoglobinopathy type (2020: SS (66%), SC (27%), Sβ-thal (6.5%) vs 2019: SS (48%), SC (42%), Sβ-thal (10%), p = 0.03), whereas there was no difference in severity on presentation measured by ESI (median score of 3: 88% vs 90%, p = 0.13) or age (30 vs 30 years old, p = 0.925). More patients in 2020 presented with dyspnea (22% vs 11%, p = 0.02), and/or nausea or vomiting (22% vs 11%, p = 0.02), but more patients in 2019 presented with cough (7% vs 17%, p = 0.025). None of the patients tested positive for SARS-CoV-2. There was no statistically significant difference between the study periods in hospitalization rate (44% vs 37%, p = 0.32), LOS (60 vs 64 hrs, p = 0.73), admission to the ICU (3% vs 2.5%, p = 1.0) or step-down unit (0% vs 1%, p = 1.0), or death (0% vs 1%, p = 1.0). There was a difference in ED re-presentation within 7 days of the index visit (14% vs 47%, p &lt; 0.001), but no difference in rate of readmission within 7 days (9% vs 15%, p = 0.225). Discussion: Although fewer patients with SCD presented for acute care in 2020, there was no significant difference in objective metrics, including admission rates, LOS, readmissions, and disease-specific complications. The decrease in ED return visits in 2020 may reflect patients' concerns regarding exposure to SARS-CoV-2 while in the ED. Our data demonstrate that although fewer patients with SCD presented for acute care utilization, they did not appear to be sicker. The data support more frequent management of uncomplicated pain crises outside of the ED, through optimization of outpatient services including infusion centers and telehealth. The advent of new care delivery models as a result of the Covid-19 pandemic may have a positive impact on frequency of ED utilization for patients with SCD. Disclosures No relevant conflicts of interest to declare.

The Association of Antibiotic (ATB) exposure prior to immune checkpoint inhibitor (ICI) treatment on early emergency room and hospitalization utilization: A population-based study.

304 Background: ICIs are becoming a common therapeutic option for many solid tumors. Prior studies have shown that ATB exposure can negatively impact ICI outcomes through gut microbiome changes leading to poorer overall survival; however, less is known about the potential impact of ATB exposure on toxicities from ICI. We undertook a population-based retrospective cohort study in patients receiving ICIs to evaluate the impact of ATB exposure on early acute care use, defined as emergency department visit or hospitalization, within 30 days of initiation of ICI therapy. Methods: Administrative data was utilized to identify a cohort of cancer patients > 65 years of age receiving ICIs from June 2012 to October 2018 in Ontario, Canada. We linked databases deterministically to obtain socio-demographic and clinical co-variates, ATB prescription claims and acute care utilization. Patients were censored if they died within 30 days of initiating ICI therapy. The impact of ATB exposure within 60 days prior to starting ICI on early acute care use was evaluated using multi-variable logistic regression models, adjusted for age, gender, rurality, recent hospitalization within 60 days prior to starting ICI and comorbidity score. Results: Among 2737 patients (median age 73 years), 43% received Nivolumab, 41% Pembrolizumab and 13% Ipilimumab, most commonly for lung cancer (53%) or melanoma (34%). Of these patients, 19% had ATB within 60 days prior to ICI with a median ATB treatment duration of 9 days (SD = 13). 647 (25%) patients had an acute care episode within 30 days of starting ICIs; 182 (7%) patients passed away within 30 days without acute care use and were censored from further analyses. Any ATB exposure within 60 days prior to ICI was associated with greater likelihood of acute care use (aOR = 1.34 95% CI [1.07-1.67] p = 0.01). A dose effect was seen based on weeks of ATB exposure within 60 days prior to ICI (aOR = 1.12 per week [1.04-1.21] p = 0.004) and early acute care use. ATB class analysis identified that exposure to penicillins (aOR = 1.54 [1.11-2.15] p = 0.01) and fluoroquinolones (aOR = 1.55 [1.11-2.17] p = 0.01) within 60 days of starting ICIs were associated with a greater likelihood of acute care use, while there was no significant association between cephalosporin exposure and early acute care use (p > 0.05). Conclusions: Exposure to ATBs, specifically fluoroquinolones and penicillins, prior to ICI therapy is associated with greater likelihood of hospitalization or emergency room visits within 30 days after initiation of ICIs, even after adjustment for relevant co-variates including age, comorbidity score and recent hospitalization prior to ICI initiation. Further studies are required to better understand the mechanisms of recent ATB exposure on early acute care use among patients receiving ICIs.

Piloting the REDUCE score to decrease acute care utilization.

252 Background: Emergency department visits and hospitalizations are common in patients with cancer, with nearly three quarters of patients with advanced disease hospitalized at least once in the year after their diagnosis. Efforts to prospectively identify patients at highest risk for this acute care utilization (ACU) are needed. While many risk scoring systems have been developed for this purpose, few have been effectively integrated into clinical practice. We piloted a prospective risk assessment tool using a quality improvement framework. Methods: We utilized our previously published REDUCE score (Reducing ED Utilization in the Cancer Experience) to pilot clinical interventions to reduce ACU using PDSA cycles. Cycle 1 included a chart review and targeted outreach by a nurse navigator to high risk patients identified by REDUCE. Outreach resulted in communication of patient needs to the care team, which may or may not have resulted in additional interventions. Cycle 2 involved initial identification by REDUCE followed by further assessment with a distress screening. Those who were high risk and had high distress (score ≥4) were discussed by an interdisciplinary team (including supportive medicine physicians, social work, nurses, nurse practitioners) to determine an appropriate intervention. Results: Of the patients in Cycle 1 (N = 138), 26.1% had ACU after outreach by a nurse navigator, while in Cycle 2 (N = 169) 7.1% had ACU after the intervention determined by the interdisciplinary team. The average distress score among all patients in Cycle 2 was 6.0 and the REDUCE score was 2.87, while the subset of patients who experienced ACU had an average distress score of 6.4 and a REDUCE score of 3.22. Conclusions: The REDUCE score may be a valuable tool to assist in identifying patients at risk for ACU. We found that combining the risk score with a biopsychosocial screening tool and multidisciplinary team discussion may prove more valuable than the risk score alone, with Cycle 2 findings suggesting that there is a directional correlation between REDUCE score and distress screening results. More work is needed to understand the relative impact of the REDUCE score and the biopsychosocial screening and team discussion on decreasing ACU.