Physical Therapy Utilization Among Hospitalized Patients with Pediatric Acute Lymphoblastic Leukemia

Background: Pediatric acute lymphoblastic leukemia (ALL) patients have excellent survival outcomes, yet remain at increased risk for impaired physical function due to multiple chemotherapy-associated conditions including myopathy, peripheral neuropathy, bone toxicities, and fatigue. While initiating physical therapy (PT) early in treatment is likely to improve physical function and overall health of children with ALL, there are no published recommendations to guide PT service delivery for this population. In fact, utilization of PT and factors associated with utilization during planned and unplanned hospitalizations are not known. We sought to determine patterns of inpatient PT utilization in pediatric ALL patients, and its association with patient and hospital factors. Methods: Leveraging the Premier Healthcare Database, we conducted a cohort study that included participants hospitalized with ALL at 0-21 years of age from January 1, 2010 through March 31, 2017. Patients who underwent bone marrow transplant or had traumatic injuries unrelated to ALL therapy were excluded. The primary outcome was receipt of inpatient PT, identified by billing claims, within one year of first hospitalization. A multivariable logistic regression model was used to estimate odds ratios (OR) and 95% confidence intervals (CI) of sociodemographic and clinical variables associated with PT. Results: Our cohort included 5,488 pediatric ALL patients admitted to 330 hospitals (42.3% female, 56.0% White, median age 7 years). Among these patients, 1,491 (27.2%) received PT within one year of their first admission, with 840 (15.3%) receiving PT during their first admission (Figure). For inpatient hospital stays in which participants received PT, the median length of stay was 9 (interquartile range [IQR] 4-18) days, and the median number of PT encounters per stay was 2 (IQR 1-4). Of 426 patients who had a diagnosis of peripheral neuropathy (n=334), myopathy (n=35), or avascular necrosis (n=74), 251(58.9%) received PT within a year of their first ALL admission. Compared with patients 0-4 years old, those aged 5-9 were less likely to receive PT (OR=0.71, 95% CI: 0.60-0.84), while those aged 10-14 (OR=1.38, 95% CI: 1.15-1.66) and 15-21 (OR=1.44, 95% CI: 1.20-1.73) were more likely to receive PT (Table). Patient factors associated with receiving PT included Hispanic ethnicity (OR=1.22, 95% CI: 1.01-1.46) and a history of an intensive care unit stay (OR=2.67, 95% CI: 2.28-3.11). Patients at teaching hospitals (OR= 1.64, 95% CI 1.39-1.89) were more likely to receive PT than those at non-teaching hospitals, while patients at rural hospitals (OR=0.39, 95% CI: 0.27-0.56) were less likely to receive PT than those at urban hospitals. Compared to patients treated by a pediatric hematologist/oncologist, patients treated by a non-hematology/oncology pediatric (OR=0.53, 95% CI:0.44-0.63) or adult (OR=0.46, 95% CI:0.37-0.57) specialist were less likely to receive PT. PT utilization also varied significantly by geographic region, and hospital size, while patient sex and insurance coverage did not appear to impact PT utilization (Table). Conclusions: Less than 30% of pediatric ALL patients receive inpatient PT within a year of their first hospitalization. Interventions to increase inpatient PT services to pediatric ALL patients and address disparities in PT utilization would be desirable to improve the physical function and long-term health of survivors. Figure 1 Figure 1. Disclosures Ma: Celgene/Bristol Myers Squibb: Consultancy, Research Funding.

The Potential Risk of Using Historic Claims to Set Bundled Payment Prices: The Case of Physical Therapy After Lower Extremity Joint Replacement

Background One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients.Methods This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015-2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen.Results The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor ‘presence of supplementary insurance’ was the strongest predictor for post-discharge PT utilization in both groups (TKA: β=7.46, SE=0.498, p-value<0.001; THA: β=5.72, SE=0.515, p-value<0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller.Conclusions This study shows that enabling factors such as the presence of supplementary insurance can cause historic claims-based pricing methods to potentially overestimate clinically appropriate post-discharge PT use, which would result in a bundle price that is too high. Clinical guidelines and best practice standards should be leveraged more often in bundled payment pricing methods to target this potentially avoidable utilization of care, and to stimulate the implementation of multi-provider bundled payment contracts.

A framework ensemble facilitates high Pt utilization in a low Pt loading fuel cell

Rationally designing the structure of catalyst layer in MEA to achieve the dispersion of active sites at the cross of three-phase field and the effective transfer network paths for protons through catalysts and catalyst layer.

Correction: A framework ensemble facilitates high Pt utilization in a low Pt loading fuel cell

Correction for ‘A framework ensemble facilitates high Pt utilization in a low Pt loading fuel cell’ by Jian Wang et al., Catal. Sci. Technol., 2021, DOI: 10.1039/d1cy00028d.

Graphene-Quantum-Dots-Composited Platinum Nanotube Arrays as Dual Efficient Electrocatalyst for Oxygen Reduction Reaction and Methanol Electro-Oxidation

Platinum (Pt) is an excellent electrocatalyst for the cathode and anode reactions in direct methanol fuel cells (DMFCs). However, constructing nanostructures with efficient Pt utilization and electrocatalytic activity is a...

Structure, Morphology and Catalytic Activity of PtRu/RGO Prepared by Different Processes

With the aim of developing an active catalyst for a direct methanol fuel cell and its preparation process, PtRu supported on reduced graphene oxide (RGO), PtRu/RGO, was prepared by three different processes using RGO with different sizes, i.e., large and small. The first process (A) involves the drying of RGO, the second one (B) does not involve the drying, and the third one (P) also does goes not involve the drying but goes through a polydopamine modification. (A) results in large agglomerates of RGO due to stacking and PtRu also formed agglomerates of nanoparticles on the outer surface of the RGO agglomerates. (B) resulted in a low Pt utilization due to the stacking of RGO. (P) improved its ECSA, Pt utilization and mass activity due to the modification that allows a homogeneous and small size PtRu deposition on the RGO. However, a problem with the modification that reduce the positive interaction between PtRu and RGO was also suggested. A smaller RGO was preferred in (P), but not in (A) and (B).