Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California.

The impacts of homelessness on health and health care access are detrimental. Intervention and efforts to improve outcomes and increase availability of affordable housing have mainly originated from the public health sector and government. The role that large community-based health systems may play has yet to be established. This study characterizes patients self-identified as homeless in acute care facilities in a large integrated health care system in Northern California to inform the development of collaborative interventions addressing unmet needs of this vulnerable population. The authors compared sociodemographic characteristics, clinical conditions, and health care utilization of individuals who did and did not self-identify as homeless and characterized their geographical distribution in relation to Sutter hospitals and homeless resources. Between July 1, 2019 and June 30, 2020, 5% (N = 20,259) of the acute care settings patients had evidence of homelessness, among which 51.1% age <45 years, 66.4% males, and 24% non-Hispanic Black. Patients experiencing homelessness had higher emergency department utilization and lower utilization of outpatient and urgent care services. Mental health conditions were more common among patients experiencing homelessness. More than half of the hospitals had >5% of patients who identified as homeless. Some hospitals with higher proportions of patients experiencing homelessness are not located near many shelter resources. By understanding patients who self-identify as homeless, it is possible to assess the role of the health system in addressing their unmet needs. Accurate identification is the first step for the health systems to develop and deliver better solutions through collaborations with nonprofit organizations, community partners, and government agencies.

Excessive Weight Gain: Current Antiretroviral Agents in Virologically Suppressed People with HIV.

An observational cohort study was conducted with data from the Observational Pharmaco-Epidemiology Research & Analysis (OPERA) cohort to investigate weight gain among virologically suppressed people with HIV (PWH) switching to regimens containing tenofovir alafenamide/emtricitabine/(TAF/FTC). Virologically suppressed, antiretroviral therapy (ART)-experienced PWH switching to TAF/FTC with darunavir/cobicistat (DRV/c), elvitegravir/cobicistat (EVG/c), dolutegravir (DTG), or bictegravir (BIC) were selected. Cox proportional hazards models were used to assess the risk of excessive weight gain (i.e., ≥5% gain within 28 weeks or ≥10% within 54 weeks), by regimen. A linear mixed effects model with random intercept and restricted cubic splines on time was used to assess continuous changes in weight. Confounding was controlled for with both inverse probability of treatment weighting and traditional covariate adjustment. Among 5,536 PWH, 18% gained ≥5% of their weight within 28 weeks, and 9% gained ≥10% within 54 weeks. There were no differences in the risk of excessive weight gain by regimen, although there was a nonstatistically significant 20% increase in the risk of gaining ≥10% within 54 weeks with all regimens compared to DRV/c. Throughout follow-up, the mean predicted weight remained fairly constant, with no notable differentiation between regimens. Expected weight gains ranged from +0.2 to +0.3 kg at 6 months and from +0.5 to +0.6 kg at 24 months. In conclusion, in this study of virologically suppressed, ART-experienced PWH switching to regimens containing TAF/FTC and DRV/c, EVG/c, DTG, or BIC, up to 18% experienced excessive levels of weight gain. However, no statistically significant difference was observed across regimens.

Factors Associated With Unplanned Acute Care Services for Patients With Newly Diagnosed Hematologic Malignancies.

PURPOSE: This study evaluated risk factors predicting unplanned 30-day acute service utilization among adults subsequent to hospitalization for a new diagnosis of leukemia, lymphoma, or myeloma. This study explored the prevalence of medical complications (aligned with OP-35 measure specifications from the Centers for Medicare & Medicaid Services [CMS] Hospital Outpatient Quality Reporting Program) and the potential impact of psychosocial factors on unplanned acute care utilization. METHODS: This study included 933 unique patients admitted to three acute care inpatient facilities within a nonprofit community-based health care system in southern California from 2012 to 2017. Integrated comprehensive data elements from electronic medical records and facility oncology registries were leveraged for univariate statistics, predictive models constructed using multivariable logistic regression, and further exploratory data mining, with predictive accuracy of the models measured with c-statistics. RESULTS: The mean age of study participants was 65 years, and 55.1% were male. Specific diagnoses were lymphoma (48.7%), leukemia (35.2%), myeloma (14.0%), and mixed types (2.1%). Approximately one fifth of patients received unplanned acute care services within 30 days postdischarge, and over half of these patients presented with one or more symptoms associated with the CMS medical complication measure. The predictive models, with c-statistics ranging from 0.7 and above for each type of hematologic malignancy, indicated good predictive qualities with the impact of psychosocial functioning on the use of acute care services (P values < .05), including lack of consult for social work during initial admission (lymphoma or myeloma), history of counseling or use of psychotropic medications (lymphoma), and past substance use (myeloma). CONCLUSION: This study provides insights into patient-related factors that may inform a proactive approach to improve health outcomes, such as enhanced care transition, monitoring, and support interventions.

Impact of Behavioral Health Screening on Proactive Identification of Patients at Risk for Hospital Readmission.

Improving the ability to predict which patients are at increased risk for readmission can lead to more effective interventions and greater compliance with CMS Hospital Readmissions Reduction Program (HRRP) requirements. This study evaluated the performance of a risk model that used data from a health system's electronic medical record (EMR) to predict all-cause readmission among adult inpatients with acute medical conditions, with a specific focus on the impact of including behavioral health screening data. The study included 39,155 unique adult patients admitted during 2015 to 4 acute care inpatient facilities within a nonprofit community-based health care system. The risk model integrated a comprehensive set of data elements including demographics, psychosocial characteristics, medical history, assessment results, and clinical events. Predictive models were constructed using a multivariable logistic regression with a stepwise selection approach. Among study participants, the mean age was 62.9 years, 48.0% were male, 31.2% had comorbid psychiatric conditions, and 6986 had medical conditions/procedures subject to HRRP penalties. Results from exploratory predictive analyses demonstrated that any patients with a Serious Mental Illness (SMI) diagnosis were 28% more likely to be readmitted within 30 days, and the likelihood of readmission associated with SMI increased to 56% for patients with medical conditions subject to HRRP penalties. As health care systems face increasing pressures to reduce readmissions and avoid CMS HRRP financial penalties, study results indicate the importance of including behavioral health data from EMRs and screening assessments for all inpatients to improve discharge planning and patient outcomes.

Inpatient resource use and cost burden of deep vein thrombosis and pulmonary embolism in the United States.

PURPOSE: Venous thromboembolism (VTE), which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), is associated with significant morbidity and mortality. VTE frequently leads to hospitalization and represents a considerable economic burden to the US health care system. However, little information exists on the duration of hospitalization and associated charges among patients with an admitting or primary diagnosis of DVT or PE. This study assessed the charges associated with hospitalization length of stay in patients with DVT or PE discharged from US hospitals in 2011. METHODS: Using data from the Nationwide Inpatient Sample of the Healthcare Utilization Project database, this analysis examined hospital length of stay and associated charges in patients with DVT or PE discharged from US hospitals in 2011. Both initial and subsequent hospitalizations were analyzed. FINDINGS: DVT was responsible for fewer hospitalizations than PE. In 2011, among 330,044 patients with VTE discharged from US hospitals, 143,417 had DVT and 186,627 had PE. Mean length of stay for patients with DVT was 4.7 days (median, 3.9 days) compared with 5.1 days (median, 4.5 days) for patients with PE. For initial hospitalizations, the mean (SE) charge amounted to $30,051 ($246) for DVT compared with $37,006 ($214) for PE. Older patients with PE incurred greater hospital charges than younger ones, and for both DVT and PE patients, women incurred greater charges than men. Of 31,463 patients admitted to the hospital with PE, 4.0% had a subsequent admission, which was more costly than the initial admission. Many patients with both DVT and PE were discharged to specialist nursing facilities, indicating continuing posthospitalization charges. IMPLICATIONS: Hospital stays for DVT and PE represent a substantial cost burden to the US health care system. Health care systems have the potential to reduce the clinical and economic burden of VTE by ensuring that evidence-based, guideline-recommended anticoagulation therapy is adhered to by patients with an initial VTE. Appropriate anticoagulant therapy and continuity of care in these patients may reduce the incidence and frequency of hospital readmissions and VTE-related morbidity and mortality and have a potential effect on health care resources.

Gastrointestinal comorbidities associated with atrial fibrillation.

This observational study was conducted to describe the risk of gastrointestinal (GI) events among patients with atrial fibrillation (AF). We analyzed Thomson Reuters MarketScan® data from 2005 to 2009. Subjects aged ≥18 years with ≥ 1 AF diagnosis were selected. GI events were identified from claims with a primary or secondary diagnosis code for any GI condition. The risk of GI events was assessed using cumulative incidence (new GI events/patients with AF without GI condition at baseline) and incidence rates (IRs), calculated as the number of patients with new GI events divided by patient-years of observation. In addition, the CHADS2 score was evaluated at baseline to determine the patient's risk of stroke. A total of 557,123 AF patients were identified. The mean (median) AF patient age was 68.2 years (70); 45% were female. The cumulative incidences of any GI event and dyspepsia were 40% and 19%, respectively. The corresponding IRs were 38.8 and 14.7 events per 100 patient-years. IRs of any GI events for female and male patients were 43.6 and 35.5; for patients in the age groups <65, 65-74, 75-84, and ≥85 years, IRs were 32.3, 38.9, 44.6, and 52.7; for patients with a CHADS2 score of 0, 1-2, 3-4, and 5-6, IRs were 30.3, 41.6, 56.9, and 74.5, respectively. In this large claims database, 40% of AF patients experienced a GI event, predominantly dyspepsia. Physicians should take age and comorbidities into consideration when managing AF patients.

The economic impact of acute coronary syndrome on length of stay: an analysis using the Healthcare Cost and Utilization Project (HCUP) databases.

OBJECTIVE: To assess the economic impact of initial and repeat hospitalizations associated with acute coronary syndrome (ACS) over 1 year (2009). DESIGN AND METHODS: National- and state-level data on length of stay (LOS) and related charges for ACS-associated hospital admissions were assessed using two Healthcare Utilization Project databases. The first, the Nationwide Inpatient Sample (NIS), provided clinical and resource use information from ∼8 million hospital stays, representing a 20% stratified sample of ∼40 million annual hospital stays in the US in 2009. The second, the State Inpatient Databases, provided 100% of inpatient data from nine states that included both patient age and linked information on multiple patient admissions within the same calendar year. For patients with repeat admissions, the LOS, primary diagnosis, and total charges between the first and subsequent admissions were evaluated. All patients≥18 years of age with at least one diagnosis of ACS, defined using the International Classification of Diseases, 9th Revision, were included (code 410.xx [except 410.x2], 411.1x and 411.8x). Variables evaluated for each discharge included demographics, cardiovascular events and procedures, LOS, discharge status, and total charges. RESULTS: The NIS reported 1,437,735 discharges for ACS in 2009. In this dataset, mean LOS for an initial ACS event was 5.56 days. Patients>65 years of age had the highest numbers of admissions; this group also had the most comorbidities. Approximately 40% of ACS patients with data on repeat visits had more than one admission, >70% of these within 2 months of the primary discharge. Mean charges were $71,336 for the first admission and $53,290 for the second admission. CONCLUSION: Despite a variety of new therapies to prevent ACS, it remains a common condition. Better therapies are called for if the clinical and cost burden of ACS is to be alleviated.

Burden of comorbidities among patients with atrial fibrillation.

OBJECTIVE: This study examined comorbidity prevalence and general medication use among individuals with atrial fibrillation in the United States to convey a more comprehensive picture of their total disease burden. METHODS: This was a retrospective, observational evaluation of responses to the 2009 wave of the annual Internet-based National Health and Wellness survey, which collects health data including epidemiologic data and information on medical treatment from a representative nationwide sample of adults in the United States. Responses were assessed to determine three measures of comorbidity: mean number of comorbidities, CHADS2 score reflecting stroke risk (0-6 points; low risk: 0; moderate risk: 1; high risk: ≥ 2), and scores on the Charlson Comorbidity Index, which is a measure of general comorbidity reflecting presence of a wide range of comorbidities. RESULTS: Of the overall sample, 1297 participants reported having been diagnosed with atrial fibrillation. Almost all (98%) of the predominantly male (65.1%) and older (≥ 65 years of age, 65.7%) population with atrial fibrillation had at least one additional comorbidity, and 90% had cardiovascular comorbidities. On the Charlson Comorbidity Index, 44.9% of the respondents had scores of 1-2 and 20.5% had scores of 3 or higher. High risk for stroke, demonstrated by a CHADS2 score of at least 2, was present in 45% and moderate risk (CHADS2 score 1) in 36%. Of the respondents with atrial fibrillation, 71% reported current use of medication to manage the condition, but only 48% of individuals at high risk for stroke reported use of anticoagulation therapy. Of those who reported having common risk factors for stroke, the majority reported receiving prescription therapy for these conditions. CONCLUSIONS: The health burden carried by patients often extends far beyond atrial fibrillation. Physicians should carefully consider comorbidities and concomitant medications when managing patients with atrial fibrillation.

Dyspepsia and disease burden among patients with atrial fibrillation.

This retrospective, observational study was conducted to determine overlap of prevalence between atrial fibrillation (AF), an increasingly common condition that primarily affects the elderly population, and dyspepsia, which is also common. Because the overlap of these conditions could interfere with health care including medication selection, the effect on patient outcomes was also evaluated. A demographically representative population of adults in the United States self-administered an Internet-based questionnaire, and responses were evaluated to determine the presence of AF and measures of comorbidity, including CHADS2 score of stroke risk. Health-related quality of life, work productivity and activity impairment, and health care resource utilization were also assessed. The impact of dyspepsia on these patient outcomes was then examined with multiple regressions and generalized linear models. From the sample population, 1297 participants reported being diagnosed with AF, of whom 34% (449/1297) reported diagnosis of dyspepsia. Those with dyspepsia had a higher mean CHADS2 score than those without dyspepsia. Despite this higher risk, significantly fewer AF patients with dyspepsia than those without dyspepsia were taking either prescription medication to treat AF or anticoagulants for stroke prevention. Dyspepsia was associated with significantly lower levels of both mental and physical health-related quality of life. Work and activity impairment and health care resource utilization were also significantly higher among AF patients with dyspepsia than among those without. The burden of dyspepsia in AF patients should be considered during medication selection. Selection of agents associated with lower rates of dyspepsia may lead to greater patient acceptance of and adherence to therapy.

Risks and cost burden of venous thromboembolism and bleeding for patients undergoing total hip or knee replacement in a managed-care population.

BACKGROUND: Total hip and total knee replacement (THR/TKR) patients are at increased risk of developing venous thromboembolism (VTE). VTE prevention using anticoagulation therapy increases the risk of bleeding. Therefore, any assessment of the cost of VTE and its prevention should also take into consideration risks and costs of bleeding. OBJECTIVE: To assess the risks of developing VTE and bleeding in patients after THR or TKR given real-world use of thromboprophylaxis, and to quantify the incremental cost associated with each. METHODS: Analyses of insurance healthcare claims from the Ingenix IMPACT National Managed Care Database(TM) from January 2004 to December 2008 were conducted. Subjects were ≥18 years and had ≥1 procedure code for THR or TKR. Patients had to have ≥180 days of observation prior to surgery and were observed for ≤3 months after THR or TKR. VTE was defined as ≥1 diagnosis code for deep vein thrombosis or pulmonary embolism. Bleeding events were classified as major or non-major. Risks of VTE or bleeding events were calculated as number of patients with an event divided by number of patients with the procedure. Incremental all-cause healthcare costs associated with VTE or bleeding were calculated as the difference between cohorts of patients without VTE or bleeding matched 1:1 to patients with VTE or bleeding. RESULTS: Of 119,729 patients (43,670 THR and 76,059 TKR), 7974 had a VTE event and 4849 had a bleeding event (2216 major bleeding [a subset of 'any bleeding']). The risks of VTE, any bleeding, and major bleeding were 6.7, 4.0, and 1.9 events, respectively, per 100 patients. Up to 3 months after THR/TKR, mean incremental all-cause healthcare costs per patient per month associated with VTE, bleeding, and major bleeding were $2729, $2696, and $4304, respectively. Total monthly costs versus matched controls over 3 months were: VTE: $12,333 vs. $9604; any bleeding: $12,481 vs. $9785; major bleeding: $14,015 vs. $9710; p < 0.001 for all. LIMITATIONS: Key limitations included potential inaccuracies or omissions in procedures, diagnoses, or costs of claims data; lack of information on the amount of blood transfused or decreases in the hemoglobin level to evaluate the severity of a bleeding event; and potential biases due to the observational design of the study. CONCLUSION: From the managed-care population perspective, in THR/TKR patients the greater incidence of VTE compared to any bleeding and major bleeding translated into a higher cumulative cost burden.