Patients with alcohol-related liver disease hospitalized during the COVID-19 pandemic experienced worse outcomes.

INTRODUCTION AND OBJECTIVES: Psychosocial stressors related to the coronavirus-19 (COVID-19) pandemic increased alcohol consumption. The effect on patients with alcohol-related liver diseases remains unclear. MATERIALS AND METHODS: Hospitalizations at a tertiary care center due to alcohol-related liver disease from March 1 through August 31 in 2019 (pre-pandemic cohort) and 2020 (pandemic cohort) were reviewed retrospectively. Differences in patient demographics, disease features, and outcomes were estimated in patients with alcoholic hepatitis utilizing T-tests, Mann-Whitney tests, Chi-square and Fisher Exact Tests and Anova models and logistic regression models in patients with alcoholic cirrhosis. RESULTS: 146 patients with alcoholic hepatitis and 305 patients with alcoholic cirrhosis were admitted during the pandemic compared to 75 and 396 in the pre-pandemic cohort. Despite similar median Maddrey Scores (41.20 vs. 37.45, p=0.57), patients were 25% less likely to receive steroids during the pandemic. Patients with alcoholic hepatitis admitted during the pandemic were more likely to have hepatic encephalopathy (0.13; 95% CI:0.01, 0.25), variceal hemorrhage (0.14; 95% CI:0.04, 0.25), require oxygen (0.11; 95% CI:0.01, 0.21), vasopressors (OR:3.49; 95% CI:1.27, 12.01) and hemodialysis (OR:3.70; 95% CI:1.22, 15.13). On average, patients with alcoholic cirrhosis had MELD-Na scores 3.77 points higher (95% CI:1.05, 13.46) as compared to the pre-pandemic and had higher odds of experiencing hepatic encephalopathy (OR:1.34; 95% CI:1.04, 1.73), spontaneous bacterial peritonitis (OR:1.88; 95% CI:1.03, 3.43), ascites (OR:1.40, 95% CI:1.10, 1.79), vasopressors (OR:1.68, 95% CI:1.14, 2.46) or inpatient mortality (OR:2.00, 95% CI:1.33, 2.99) than the pre-pandemic. CONCLUSIONS: Patients with alcohol-related liver disease experienced worse outcomes during the pandemic.

THE INTERMEDIATE ROLE OF SUPPLY CHAIN INNOVATION ON THE EFFECT OF INNOVATIVE LEADERSHIP ON SUPPLY CHAIN PERFORMANCE

In the study, the mediating role of supply chain innovation on the effect of innovative leadership on supply chain performance is investigated. Although there are many studies in the literature on the factors affecting supply chain innovation and supply chain performance, there are very few studies that include the innovative leadership effect. It is thought that the research subject, the model developed for the study, the applied sector (health services) and the findings would contribute to the literature. The reason for the selection of the health sector for the study is the fact that the Covid 19 pandemic has increased the importance of healthcare supply all over the world. In this context, the hypotheses of the study are tested with multiple regression analyzes with the data obtained from 418 public and private hospitals in Turkey by using a five-point Likert type questionnaire as the data collection method in the research. As a result of the analyzes made it is determined that innovative leadership and supply chain innovation have positive effects on supply chain performance. In the study, it is also seen that supply chain service and process innovation have a mediating role in the effect of innovative leadership on supply chain speed and environmental performance. (English) [ FROM AUTHOR]

Retrospective Analysis of Vaccinated and Unvaccinated Monoclonal Antibody Patients and their Emergent Needs (RAVEN) and Hospital Utilization

Background. Strategies to combat COVID include vaccines and Monoclonal Antibody Therapy (MAB). While vaccines aim to prevent symptom development, MAB aims to prevent progression of mild symptoms to severe. Increasing numbers of COVID infections in vaccinated patients raised the question of whether vaccinated and unvaccinated patients respond differently to MAB. Methods. We performed a retrospective review of the medical charts to evaluate responses of MAB in vaccinated and unvaccinated COVID patients by measuring the number of emergency department (ED) visits, hospitalizations, and ICU admissions within 14 days and the 30-day mortality following MAB. We evaluated outcomes according to vaccination status using absolute risk reduction and used Chi-squared tests to assess statistical significance using an alpha of p< 0.05. We used multivariable generalized linear models with a log link and binomial distribution to estimate adjusted relative risk and 95% confidence intervals. Results. Based on the inclusion criteria, we found 4,128 patients from which 230 had missing vaccination information or dose. From 3898 included patients, 296 (7.59%) visited the ED, 154 (3.95%) were hospitalized, and 25 (0.64%) were in ICU within 14 days of infusion. 12 patients (0.31%) died within 30 days. 2009 (51.5%) were unvaccinated at the time of infusion. Demographics were similar in both groups except that most of the patients in both groups were Non-Hispanic Caucasians, raising the question of racial and ethnic disparities. All comorbidities except pregnancy were predominant in the vaccinated group. Unvaccinated patients were more likely to receive MAB after 7 days of symptoms and in the ER, suggesting that they may have had more severe disease at the time of infusion, despite having less comorbidities. Unvaccinated patients had more ED visits (11.2% vs 4.3%, p< 0.0001), hospitalizations (6.2% vs 2.1%, p< 0.0001), and deaths (1.1% vs 0.3%, p=0.005) following infusion. Adjusted for demographics and comorbidities, unvaccinated patients were 2.41 times more likely to seek help in the ED and 2.73 times to be hospitalized. chronic kidney disease, cardiovascular disease, lung disease, neurological disorders, and smoking) (Figure Presented) Conclusion. Our data confirms that immunization plays a key role in reducing COVID-related morbidity and mortality. It also supports MAB efficiency from clinical trials.

Performance improvement of medical blood handling for aphaeresis platelet usage

Objectives: Medical-use Blood Handling ought to be considered as Supply Chain Management including Donation Centers, Hospitals, and blood consumers so that the Quick Response to the change of blood usages and JIT provision can be accomplished. Among others,Aphaeresis Platelet (AP) is vital few of medical blood areas due to increasing demands on higher quality from medical personnel and patients. It makes the SCM more complicated because of its short life-time and infection-sensitivity. The medical centers and hospitals may incline safety inventory and usage amount of pallets due to a speculation of possible wastes. Hence, a prediction model can contribute greatly to the balance of demand and supply of medical-use blood and avoid the wastes of vital resources such as Aphaeresis Platelet regarding its safety lifecycle. Methods: In order to remedy the negative consequence on the performance of blood provision resulted from this speculation;we need to study the correlations between the characteristics of patients as well as hospitals and the usages of Platelet Concentrated, Aphaeresis Platelet, and Prestorage Leukocyte-reduced Aphaeresis Platelets where the rate of using platelet by patients with cancers play a crucial role in developing the model to estimate the demand quantity on Aphaeresis Platelets. Aiming at this, it is crucial to develop a prediction model based on the correlations between the characteristics of patients, healthcare institutions and of the utilization of various types of AP products. By means of previous knowledge and expert interviews, we have at first set up a research framework, which involves patient characteristics, type of hospitals, utilization (rate) and their relation to derive the forecasting model. After priori-analysis on the data of 6 years, we have at first test the data by means of regression, viz. ARIMA. Further studies by means of ANOVA can be conducted to search for the correlation between patient characteristics and utilization of AP, as well as the donation conditions and blood supply, where the characteristics of cancer. At last, we have done a cross-check on aforementioned data and interpretation of the result. Results: The result of this research shows at first that there is no influence of seasons (time) to the consumption of Aphaeresis Platelet in Taiwan while unexpected incidences such as COVID-19 do influence. As the second, medical institutions of different size and level do have different consuming behaviors to AP and patients under chemical therapies consume the largest portion of platelets, that is, 36.5%. More detailed, 25.92 of the patients with cancer consume platelet concentrated, 45.80% of them takes AP and 63.07% takes Prestorage Leukocyte-reduced Aphaeresis Platelets. The effects of perceived issues and potential development of performance improvement are worthy of further investigation. Conclusions: The result of this research shows at first that there is no influence of seasons (time) to the consumption of AP in Taiwan while unexpected incidences such as COVID-19 do influence. Medical institutions of different size and level do have different consuming behaviors to AP and patients under chemical therapies consume the largest portion of platelets.

EVALUATION OF A TRANSITIONS CLINIC TO BRIDGE EMERGENCY DEPARTMENT AND PRIMARY CARE

BACKGROUND: Suboptimal transitions from emergency department (ED) to ambulatory settings contribute to poor clinical outcomes and unnecessary non-urgent ED utilization. Primary care-staffed care transition clinics (CTCs) are a potential solution to reduce ED crowding by providing ED follow-up care and facilitating the bridge to longer-term primary care. This study is a preliminary evaluation of the initiation of an ED transitions clinic on 30-day ED and hospital readmissions. METHODS: This retrospective cross-sectional study included adults discharged from the ED at UC hicago Medicine referred to the transitions clinic between November 2020 and May 2021. Appointment attendance, frequency of care type provided, and percent contacted with patient advocate were computed to assess clinic utilization. 30-day ED and hospital readmissions were compared between patients who completed their CTC appointment and patients who missed their CTC appointment using a chi-square test. RESULTS: In the first 6 months of program initiation, 116 patients were referred to the CTC from the ED and around half (47%) completed their follow-up appointment. The majority of patients were of black race (90%) and on public insurance (81%). Almost a quarter of referred patients (22%) were contacted by a patient advocate for referral to longer-term care. The most common reasons for referral were wound check (top 3: cellulitis, abscess, suture removal) and clinical problem management (top 3: SOB, chest pain, covid). Wound checks were 20% more likely to be completed compared to clinical appointments (58% show rate vs 38%). Patients who completed their CTC appointment had a lower rate of ED revisits (15% vs 20%) but the effect was not statistically significant (p>0.05). No statistically significant effects were seen for CTC appointment completion on hospital readmission. CONCLUSIONS: Transition clinics may have the potential to help reduce excess ED use for ambulatory care needs, particularly if they can help facilitate patients being connected to more permanent ambulatory care sites and clinicians. In addition to ongoing analysis of this program evaluation regarding ED and hospital utilization, additional research is needed to investigate the factors influencing follow-up completion and identifying effective interventions for increasing appointment attendance.

READMISSION RATES AMONG PATIENTS AMONG PATIENTS EXPERIENCING HOMELESSNESS IN AN INTEGRATED HEALTHCARE SYSTEM

BACKGROUND: Homelessness is a significant public health concern in the United States and is an important risk factor for poor health outcomes. There is limited data regarding the hospital utilization by this vulnerable population, especially inmanaged care settings. Historically, it has been difficult to identify patients experiencing homelessness at the population health level. In 2019, due to the passage of state law SB1152, hospitals across California now need standardized documentation policies for patients experiencing homelessness. This study assessed hospital readmission rates among hospitalized patients experiencing homelessness as identified through documentation in the electronic health record (EHR) as compared to the general hospitalized population within a large integrated health system. METHODS: This was a retrospective cohort study following adult patients (age≥18 years) hospitalized in Kaiser Permanente Northern California (KPNC) Medical Centers between 1/1/2019 through 12/1/2020. Patients were identified as homeless or housing insecure if they had SB1152 documentation, a homeless diagnosis code, or address history indicating homelessness within the extensive integrated KPNC EHR. A control group was created using 1:2 propensity score matching using Elixhauser comorbidities and demographics. Sensitivity analyses were performed to compare patients with an index hospitalization occurring during the COVID-19 shelter-in-place period between March 2020 and December 2020 with those whose index hospitalization occurred before this period. The primary outcome was 30-day readmission rate to the hospital or ED, and secondary outcomes included length of index hospitalization, and time to inpatient (IP) readmission. RESULTS: A total of 12,909 patients were included with 4,303 patients in the homeless group. Patients experiencing homelessness had increased odds for any 30-day readmission (OR 1.59;95% CI: 1.44-1.76), for inpatient readmission (OR 1.36;95% CI: 1.17-1.57), for ED readmission (OR 1.63;95% CI: 1.47-1.80), and had longer stays during their index hospitalization (IRR 1.12;95% CI: 1.04-1.21). The COVID-19 shelter-in-place period was not associated with any changes in the primary or secondary outcomes studied. CONCLUSIONS: Patients experiencing homelessness are at an increased risk for readmissions and longer hospitalizations compared to the general hospitalized population. Documentation of housing status following SB1152 has improved the ability to study hospital utilization among patients experiencing homelessness. Understanding patterns of hospital utilization in this vulnerable group will help providers to identify timely points of intervention for further social and healthcare support.

Silent Hypoxemia in Covid-19 and Non-Covid-19 Pneumonias

Rationale Multiple anecdotal reports describe patients with COVID-19 presenting with what is referred to as silent hypoxemia (without dyspnea, tachypnea, or respiratory distress). However, there is a paucity of literature on this problem. We conducted a study to determine the prevalence of silent hypoxemia in patients with COVID-19 infection at presentation in the emergency department (ED) or on admission, and compared it with that of patients with pneumonia by any other etiology at Memorial Hermann Health System. In addition, we analyzed the differences between clinical, laboratory, hospital utilization, and mortality. Methods From electronic medical records, we identified pneumonia patients with a positive result for coronavirus on reverse transcriptasepolymerase chain reaction (RT-PCR) nasopharyngeal swab test, or diagnosis of pneumonia by influenza or any other etiology for one year, presenting to the ED or admitted to any MHHS hospital. We extracted age, sex, race/ethnicity, vital signs, oxygen saturation, intensive care unit (ICU) admission, and hospital stay for all patients. Results A total of 17,475 COVID-19 patients were compared with 2,343 patients with influenza/pneumonia of any etiology. The two groups were similar with respect to age, sex, and ethnicity. The frequency of silent hypoxemia was greater in the COVID-19 (n=232, 1.3%) group compared to influenza/pneumonia (n= 3, 0.13%) patients (p<0.001). For patients with an oxygen saturation < 90, the proportion who had silent hypoxemia was 11.7% (232/1981) in the COVID-19 patients and 2.6% (3/117) in the influenza and other viral pneumonia patients. Between COVID-19 patients admitted to the hospital, patients with symptomatic hypoxemia had a longer hospital stays (median: 11 days, IQR: 6-22) compared to those with silent hypoxemia (median: 8 days, IQR: 4-18) (p=0.001). The symptomatic hypoxemia group was more likely to be admitted to the ICU (n=457, 26.1%) compared to the silent hypoxemic patients (n=33, 15.5%) (p<0.001) and the mortality rate was higher (n=454, 26.0%) vs (36, 15.5%) (p=0.001). Conclusion The prevalence of silent hypoxemia for adults with viral pneumonia who were seen in the ED or hospitalized in a 17- hospital system in Houston, was higher in the COVID-19 infection patient group compared to patients with other pneumonias or any other etiology. Among the COVID-19 subjects, those with symptomatic hypoxemia had worse outcomes compared to those with silent hypoxemia. More studies are needed to confirm these findings.

Excess All-Cause Mortality in 2020 for People Living with Sickle Cell Disease in New York City

Background The COVID pandemic resulted in excess all-cause mortality in 2020 in the United States, especially among people who identify as Black and/or Latino. While many of these deaths were due to COVID-19 infection, others have been attributed to strain on the overburdened health care system and delays in patients seeking medical care due to the pandemic. We sought to examine the overall mortality in individuals with sickle cell disease (SCD) who received their care at our Sickle Cell Center in Bronx New York in 2020 and investigated whether the number and causes of death in 2020 differed from the previous 3 years. Methods: Death date was collected from electronic medical records (EMR) and death certificates. Clinical variables collected from EMR included age, gender, race, genotype, history of comorbidities, hydroxyurea use, and health care utilization in the 12 months prior to death date. To determine cause of death, two hematologists performed manual review of the EMR blinded from each other and deaths were categorized as due to: sudden death, cardiovascular causes, sepsis, stroke, acute organ failure (including multi organ failure syndrome), chronic organ failure, hemorrhage, and unknown when records of the death event were not available. A third hematologist served as a tie breaker in cases of disagreement. Patients were also categorized as having: 1) sepsis present or absent during the death event, 2) acute (new or newly worsened) renal or liver failure present or absent during the death event, and 3) COVID status at death (acute COVID, past COVID, no COVID, or unknown COVID status). Acute COVID infection was defined by a positive PCR swab during the hospitalization leading to death or in the prior two weeks. Past COVID infection was defined by a negative PCR swab during the hospitalization and a positive PCR swab and/or antibody test more than two weeks before the death event with documented resolution of symptoms. No COVID infection was defined by a negative PCR swab or antibody test documented in the EMR and no positive tests present or noted per patient report. Unknown COVID status was unknown if no testing was present in the EMR. To examine how 2020 decedents differed from decedents in the prior 3 years, we compared clinical variables using the Kruskal Wallis test for continuous variables and chi 2 tests for dichotomous variables. To examine differences between 2020 decedents between known COVID (acute or chronic) vs. no COVID, we repeated similar tests among the 2020 decedents only. Results: In the years 2017, 2018, 2019, and 2020, there were 9, 10, 8, and 22 patient deaths respectively. Compared with decedents in the prior 3 years, patients who died in 2020 were more likely to have acute liver failure during the hospitalization, were more likely to have history of stroke, and had more heme clinic visits in the prior 12 months. Otherwise, there was no difference in age, gender, genotype, hydroxyurea use, history of disease morbidity, hospital utilization in the prior 12 months, or sepsis before death (Table 1). Among the 22 who died in 2020, 3 had an acute COVID infection, five had past COVID, 8 had no COVID, and 6 had unknown COVID status. Among 2020 decedents, acute or past covid was associated with acute organ failure (p=0.02) and less hydroxyurea use (p=0.04). (Table 2). Conclusions: SCD deaths at our center more than doubled in 2020 compared to prior years, but fewer than half of the decedents had acute or prior COVID. Compared with prior years, 2020 decedents were more likely to have acute organ failure. This could be explained by COVID infection, delays in seeking care, or changes in care delivery during the COVID pandemic. This study emphasizes the need for further studies on the impact the pandemic had on the health of adults with SCD, as well as the need for prospective studies of patients with SCD who recover from COVID. [Formula presented] Disclosures: Curtis: GBT: Consultancy. Minniti: Forma: Consultancy;GBT: Consultancy;Novartis: Consultancy;Novo Nordisk: Consultancy;Chiesi: Consult ncy;F. Hoffmann-La Roche: Consultancy;Bluebird Bio: Other: Endpoint adjudicator;CSL Behring: Other: Endpoint adjudicator.

In-hospital utilization of pre-hospital device for CPAP to manage acute respiratory failure in CoViD-19 pneumonia: findings from a single center

Background: Since February 2020, CoViD-19 spread in Italy. Acute respiratory failure (ARF) was the most relevant clinical presentation, often requiring invasive and non-invasive ventilation. We report the management of ARF in in-patients using Easy Vent Mask (EVM) system for C-PAP, a device registered for prehospital use. Methods: In this retrospective study, we included all patients admitted to Emergency Medicine Unit from March 2 to April 25, 2020 with ARF secondary to CoViD-19 pneumonia and treated with EVM system. Our aim was to evaluate the efficacy and tolerability of in-hospital use of EVM system. All demographic, clinical and treatment data were recorded. Results: Thirty patients affected by mild/moderate CoViD-19 pneumonia having PaO2/FiO2(P/F) ratio between 100 and 200 were treated with EVM system for C-PAP, of them 25(83%) were discharged and 5(17%) died in hospital. The system was well tolerated with a mean time of use of 13 consecutive days. Five patients were transferred to ICU due to failure of C-PAP treatment, of whom 3 died. Two patients died in our ward for worsening of clinical conditions. Pressure skin lesions and hypercapnia were recorded as adverse events in 24 and 2 patients respectively. Moreover, our finding showed a higher reduction of P/F value and a longer time from admission to C-PAP initiation in non-survivors, compared to survivor patients. Conclusions: EVM system for C-PAP seemed to be well tolerated and may represent an alternative to ventilators in in-hospital treatment of CoViD-19 mild/moderate pneumonia, but dedicated studies are needed.

Development and validation of a machine learning model predicting illness trajectory and hospital utilization of COVID-19 patients: A nationwide study.

OBJECTIVE: The spread of coronavirus disease 2019 (COVID-19) has led to severe strain on hospital capacity in many countries. We aim to develop a model helping planners assess expected COVID-19 hospital resource utilization based on individual patient characteristics. MATERIALS AND METHODS: We develop a model of patient clinical course based on an advanced multistate survival model. The model predicts the patient's disease course in terms of clinical states-critical, severe, or moderate. The model also predicts hospital utilization on the level of entire hospitals or healthcare systems. We cross-validated the model using a nationwide registry following the day-by-day clinical status of all hospitalized COVID-19 patients in Israel from March 1 to May 2, 2020 (n = 2703). RESULTS: Per-day mean absolute errors for predicted total and critical care hospital bed utilization were 4.72 ± 1.07 and 1.68 ± 0.40, respectively, over cohorts of 330 hospitalized patients; areas under the curve for prediction of critical illness and in-hospital mortality were 0.88 ± 0.04 and 0.96 ± 0.04, respectively. We further present the impact of patient influx scenarios on day-by-day healthcare system utilization. We provide an accompanying R software package. DISCUSSION: The proposed model accurately predicts total and critical care hospital utilization. The model enables evaluating impacts of patient influx scenarios on utilization, accounting for the state of currently hospitalized patients and characteristics of incoming patients. We show that accurate hospital load predictions were possible using only a patient's age, sex, and day-by-day clinical state (critical, severe, or moderate). CONCLUSIONS: The multistate model we develop is a powerful tool for predicting individual-level patient outcomes and hospital-level utilization.