Respiratory syncytial virus: desperately seeking solutions

Respiratory syncytial virus (RSV) infection remains a major public health problem, especially in younger children and the elderly. But several monoclonal antibodies, antivirals and vaccines, either recently launched or in development, offer new hope for RSV prevention and treatment.Copyright © 2023 Wiley Interface Ltd.

Contribution of Cardiovascular Disease to Adverse Hospital Outcomes in Covid-19 Hospitalizations: Results from National Inpatient Sample

Background It is a well-established fact that cardiovascular disease (CVD) adversely affects COVID-19 outcomes. However, the extend of the burden posed by CVD on hospitalized COVID-19 patients in the United States is unknown. In this study, using a national database, we estimated the effects CVD on COVID-19 hospitalizations in the United States. Methods This study is a retrospective analysis of National Inpatient Sample data, collected during 2020. Patients >=18 years of age, admitted with primary diagnosis of COVID-19 were included in the analysis. CVD was defined as presence of coronary artery disease, myocardial infarction, heart failure, sudden cardiac arrest, conduction disorders, cardiac dysrhythmias, cardiomyopathy, pulmonary heart disease, venous thromboembolic disorders, pericardial diseases, heart valve disorders, or peripheral arterial disease. The primary outcomes of the study were in-hospital mortality rate, prolonged hospital length of stay, mechanical ventilation, and disposition other than home. Multivariable logistic regression analysis was done to examine the association between presence of CVD and primary outcomes. Results During 2020 there were 1,050,040 COVID-19 hospitalizations in the United Sates. Of these 454650 (43.3%) had CVD. COVID-19 patients with CAD were older, males, and had higher comorbidity burden. The odds of in-hospital mortality (OR, 3.40;95% CI: 3.26-3.55), prolonged hospital length (OR, 1.71;95% CI: 1.67-1.76) and mechanical ventilation use (OR, 3.40;95% CI: 3.26-3.55), and disposition other than home (OR, 2.11;95% CI: 2.06-2.16) were significantly higher for COVID-19 hospitalizations with CAD. Mean hospitalization costs were also significantly higher among COVID-19 patients with CAD ($24,023 versus $15,320, P<0.001). The total cost of all COVID-19 hospitalizations during 2020 was $19.9 billion - $10.9 billion for those with CAD and $9.0 billion for those without CVD. Conclusion Cardiovascular disease was present in a substantial proportion of COVID-19 patients hospitalized in the United States and contributed to considerable adverse hospital outcomes and significantly higher hospitalization cost.Copyright © 2023 American College of Cardiology Foundation

The Cost of Ignoring Vaccines

This perspectives piece focuses on the detrimental cost of ignoring vaccines and refusing vaccination against COVID-19 in the United States. Much of the existing literature regarding the consequences of the unvaccinated emphasizes the impact to population health;however, few academic articles have explored the burden the unvaccinated pose to various sectors of society. This paper analyzes the impact that the unvaccinated have on healthcare systems, the US economy, and global health. Throughout the COVID-19 pandemic, unvaccinated populations were found to have put significant strain on healthcare systems, depleting medical resources and contributing to high rates of healthcare worker shortages. Furthermore, research suggests that between November and December 2021, over 692,000 preventable hospitalizations occurred in unvaccinated individuals, costing the US economy over $13.8 billion. Lastly, it is proposed that the strong international presence of the US, when coupled with high levels of disease transmissibility in the unvaccinated, provides a significant threat to global health. In conclusion, the unvaccinated have caused impacts far beyond that of population health;they have also posed a burden to healthcare systems, the economy, and global public health. Copyright © 2022, Yale Journal of Biology and Medicine Inc. All rights reserved.

RWD114 Investigating the Impacts of Comorbid Conditions on Costs and Length of Stay in Secondary Care Among Adults Infected With Influenza in England

Objectives: The burden of influenza varies across time and is affected by variations in circulating strains, population immunity, vaccination coverage and other risk factors including comorbidities and age. This study explored the impact of the presence of comorbidities on influenza-related hospitalisation costs and length of stay (LOS) in adults. Method(s): The study analysed four years of pre-COVID HES data (September 2016 - March 2020) and extracted adult patients with an influenza diagnosis (ICD-10 code J09-J11 in the primary or secondary location) in a day case or inpatient setting, identifying all patients with primary or secondary diagnosis related to any relevant comorbidity in the influenza spell. Hospitalisation costs and LOS were analysed by age, gender, and presence of comorbidities. Multi-level regression models were run on hospitalisation LOS and costs to ensure estimates captured any within-patient effects and adjusted for age, gender and other comorbid conditions. Result(s): In total, 119,495 patients were hospitalised with influenza generating a total cost of 401m, an average of 3,159 per spell. The average spell LOS and cost increased with age and the presence of comorbidities. There was a 4-day difference in median length of stay between those with and without comorbidities (6 and 2 days, respectively). Those with comorbidities recorded average costs of 3,569 compared to 1,458 for those without. Chronic heart disease was the most common comorbid condition and increased average cost even further to 4,397. Presence of comorbidities was significantly associated with hospitalisation cost;the cost for a patient with comorbidities was 214% of the cost for a patient without [95% CI 208-221%, p<0.01]. Conclusion(s): The study demonstrates the effect of comorbid conditions on influenza-related hospitalisation costs and length of stay (LOS) in adults. It strengthens the value of annual immunization for those in at-risk clinical groups in order to reduce the clinical and economic burden. Copyright © 2022

Modeling Diagnostic Testing Strategies for SARS-CoV-2 to Minimize Societal Costs and Return People to Work

Background. The shift to more transmissible but less virulent strains of SARS-CoV-2 has altered the risk calculation for infection. Particularly among young adults, the economic burden of lost work due to isolation exceeds the economic burden of morbidity due to infection. Testing strategies must adapt to these changing circumstances. Methods. We modeled six testing strategies to estimate total societal costs for symptomatic people 18-49 years old: isolation of all individuals with no testing, rapid antigen test (RAg), RAg followed by a second RAg 48h later if first negative, RAg followed by a polymerase chain reaction (PCR) if negative, RAg followed by a PCR if positive, and PCR alone. We calculated costs for hypothetical cohorts of 100 symptomatic healthcare workers tested with each strategy;we included testing costs, lost wages, and hospitalization costs for the index, secondary, and tertiary cases. Key assumptions were 5% prevalence of infection, sensitivity of first/second RAg 40/80% with 97% specificity, PCR sensitivity/specificity 95/99%, all individuals isolate at symptom onset, are tested the same day, and isolate for 5 days if positive. RAg results were available the same day, PCR results were available the next day (Figure 1). One-way sensitivity analyses were performed for RAg sensitivity (20-80%) and positivity rate (1-80%). Results. The least expensive strategy was RAg alone (Figure 2). This was primarily driven by its low sensitivity, which reduced lost wages at the expense of missing cases. At a threshold for RAg sensitivity lower than 29%, PCR testing alone became the cheapest strategy. When the positivity rate was > 6% confirming a negative RAg with a PCR became the cheapest strategy, closely followed by PCR alone. At a positivity rate of > 29%, isolation without testing was cheapest followed by confirming a negative RAg with a PCR and by the serial RAg test strategies (Figure 3). Conclusion. In relatively young, healthy populations, a single rapid test was the least expensive strategy when the positivity rate was < 6%, testing that included PCR became cheapest at intermediate positivity, and empiric isolation was cheapest at positivity > 29%. Calibrating SARS-CoV-2 test strategies based on epidemiology may save societal costs.

The Impact of COVID-19 Pandemic on Ischemic Stroke Patients in a Comprehensive Hospital.

Purpose: This study aimed to investigate the impact of characteristic ischemic stroke and outcomes during the first COVID-19 pandemic lockdown. Patients and Methods: A retrospective, observational cohort study of a comprehensive tertiary stroke center was conducted. Patients with ischemic stroke were divided into pre-COVID-19 lockdown (11/1/2019 to 1/30/2020) and COVID-19 lockdown (1/31/2020 to 4/30/2020) period groups. Patient data on stroke admission, thrombolysis, endovascular treatment, and 3-month routine follow-up were recorded. Data analysis was performed using SPSS according to values following a Gaussian distribution. Results: The pre-COVID-19 lockdown period group comprised 230 patients compared to 215 patients in the COVID-19 lockdown period group. Atrial fibrillation was more predominant in the COVID-19 lockdown period group (11.68% vs 5.65%, p=0.02) alongside patients who were currently smoking (38.8% vs 28.7%, p=0.02) and drinking alcohol (30.37% vs 20.00%, p=0.012) compared with that of the pre-COVID-19 lockdown period group. For patients receiving thrombolysis, the median door-to-CT time was longer in the COVID-19 lockdown period group (17.0 min (13.0, 24.0) vs 12.0 min (8.0, 17.3), p=0.012), median door to needle time was 48.0 minutes (35.5, 73.0) vs 43.5 minutes (38.0, 53.3), p=0.50, compared with that of the pre-COVID-19 lockdown period group. There were no differences for patients receiving mechanical thrombectomy. The median length of hospitalization (IQR) was no different. Discharge mRS scores (IQR) were higher in the COVID-19 lockdown period group (1.0 (1.0, 3.0) vs 1.0 (1.0, 2.0), p=0.022). Compared with the pre-COVID-19 lockdown period, hospitalization cost (Chinese Yuan) in the COVID-19 period group was higher (13,445.7 (11,009.7, 20,030.5) vs 10,799.2 (8692.4, 16,381.7), p=0.000). There was no difference observed in 3-month mRS scores. Conclusion: Patients presenting with ischemic stroke during the COVID-19 pandemic lockdown period had longer median door-to-CT time and higher hospitalization costs. There were no significant differences in 3-month outcomes. Multidisciplinary collaboration and continuous workflow optimization may maintain stroke care during the COVID-19 pandemic lockdown.

Modeling the impact of COVID-19 pandemic-driven increases in alcohol consumption on health outcomes and hospitalization costs in the United States.

BACKGROUND AND AIMS: Alcohol consumption increased in the early phases of the COVID-19 pandemic in the United States. Alcohol use disorder (AUD) and risky drinking are linked to harmful health effects. This paper aimed to project future health and cost impacts of shifts in alcohol consumption during the COVID-19 pandemic. DESIGN: An individual-level simulation model of the long-term drinking patterns for people with life-time AUD was used to simulate 10 000 individuals and project model outcomes to the estimated 25.9 million current drinkers with life-time AUD in the United States. The model considered three scenarios: (1) no change (counterfactual for comparison); (2) increased drinking levels persist for 1 year ('increase-1') and (3) increased drinking levels persist for 5 years ('increase-5'). SETTING: United States. PARTICIPANTS: Current drinkers with life-time AUD. MEASUREMENTS: Life expectancy [life-years (LYs)], quality-adjusted life-years (QALYs), alcohol-related hospitalizations and associated hospitalization costs and alcohol-related deaths, during a 5-year period. FINDINGS: Short-term increases in alcohol consumption (increase-1 scenario) resulted in a loss of 79 000 [95% uncertainty interval (UI]) 26 000-201 000] LYs, a loss of 332 000 (104 000-604 000) QALYs and 295 000 (82 000-501 000) more alcohol-related hospitalizations, costing an additional $5.4 billion ($1.5-9.3 billion) over 5 years. Hospitalizations for cirrhosis of the liver accounted for approximately $3.0 billion ($0.9-4.8 billion) in hospitalization costs, more than half the increase across all alcohol-related conditions. Health and cost impacts were more pronounced for older age groups (51+), women and non-Hispanic black individuals. Increasing the duration of pandemic-driven increases in alcohol consumption in the increase-5 scenario resulted in larger impacts. CONCLUSIONS: Simulations show that if the increase in alcohol consumption observed in the United States in the first year of the pandemic continues, alcohol-related mortality, morbidity and associated costs will increase substantially over the next 5 years.

IMPACT OF ENHANCED DISCHARGE EDUCATION ABOUT SEPSIS ON 30-DAY SEPSIS READMISSIONS: QUALITY IMPROVEMENT PILOT PROGRAM AT A LARGE TERTIARY CARE CENTER

SESSION TITLE: Sepsis: Beyond 30cc/kg and Antibiotics SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Sepsis is the leading cause of hospitalization and mortality in the United States. In addition, sepsis is, by volume, the leading cause of 30 day readmissions across all payer mix in the United States. The risk factors for 30 day readmissions are multifactorial and often portends poor outcomes and increase hospitalization costs. We trialed a pilot program of enhanced sepsis discharge education which consisted of direct patient education prior to discharge, providing a Sepsis Education brochure with tips on self management at home as well as a QR code to direct patients to institutional website in case they needed further assistance, and finally a disposable thermometer to maintain an accurate temperature log to aid in monitoring for signs and symptoms of sepsis. Our primary goal was educate patients about their diagnosis and reduce sepsis readmissions in all non-medicare patients being discharged home. METHODS: The pilot was implemented at on one med/surg unit in our 550-bed tertiary, academic medical center starting in March 2021 and progressively expanded hospital wide over the next six months. The sepsis administrative coordinator screens new in-patient admissions for sepsis (non-Medicare) patients daily and informs medical/surgical unit coordinators of potential candidates. Med/surg coordinators will confirm if patients meet criteria for follow-up (non-Medicare, being discharged to home), provide discharge education and enter the patient in a log for continued surveillance. Subsequently, the administrative coordinator then follows up with a phone call 7-10 days after discharge during which, they assess the patient for worrisome symptoms, confirms follow up appointments, medication compliance and review of temperature log. If the patient needs clinical assistance, they will refer to the patient to the hospital sepsis clinical coordinator or patient’s outpatient physicians. RESULTS: We compared sepsis discharges and 30day readmissions (all excluding COVID-19 cases) from March 1, 2019 – Dec 31, 2019 to March 1, 2021 – Dec 31, 2021. Readmissions amongst Medicare patients discharged home was 15.9 % (110 / 962) in 2019 vs 11.9% (83 / 696) in 2021. For non-medicare patients, the rate was 13.2% (41/311) in 2019 vs 13.1% (51/390) in 2021. In our pilot program, the readmission rate in medicare patients was 17.2% (28/163) versus 5.6% (5/90) in non-medicare patients. CONCLUSIONS: This program captures a patient population which may have been lost to follow-up. Implementation of the enhanced Sepsis Discharge Education led to at least a 30 patient reduction in readmissions yielding an approximate cost savings of $594,000. CLINICAL IMPLICATIONS: Providing educational support, instructions, and follow up calls upon discharge improves medication adherence, compliance, and maintains patient follow up thus reducing readmissions and improving hospital resource utilization and overall cost. DISCLOSURES: No relevant relationships by Laura Freire No relevant relationships by Nirav Mistry No relevant relationships by Caitlin Tauro

Trends and Outcomes of Early vs Late Discharge After Percutaneous Edge-to-Edge Mitral Valve Repair: A Nationwide Analysis

Background: Percutaneous edge-to-edge mitral valve repair (PMVR) use to manage patients with severe mitral regurgitation has been increasingly used over the past decade. Minimizing unnecessary hospital stays after elective procedures, including PMVR, has been an ongoing trend particularly since the COVID-19 pandemic to minimize patients’ exposure. Here we aim to evaluate trends and outcomes of early discharge post-PMVR. Methods: The Nationwide Readmissions Database 2016-2019 was queried for hospitalizations for PMVR. According to discharge day, hospitalizations were stratified into early discharge (<2 days from index admission) versus late discharge (≥ day 2) groups. Multivariable regression analyses were used to determine the association between discharge timing and 90-days readmission rates. Results The final analysis included 15,521 hospitalizations with 9,396 (60.5%) in the early discharge and 6,125(39.5%) in the late discharge groups with a mean age of 78.1±8.0 vs 78.5±8.7 years consecutively. Women made up 44% and 48% of the early vs late group. There was an increasing trend of early discharge post PMVR (Ptrend <0.001) (Figure). Early discharge was associated with lower odds of 90 days all-cause (adjusted odds ratio[aOR]:0.61;CI 0.55-0.68;P<0.01) and congestive heart failure readmission (aOR: 0.68: CI 0.60-0.77;P <0.01). Moreover, hospitalization costs were reduced by $6,584 (CI: 4,910- 8,257$). Conclusion. There has been an increased rate of early discharge post PMVR without an increased rate of readmission risk. Further randomized controlled studies are needed to validate these findings. [Formula presented]

HOSPITALIZATION COSTS ATTRIBUTED TO COVID-19WITHIN THE VETERANS ADMINISTRATION AND DEPARTMENT OF DEFENSE

BACKGROUND: Healthcare costs in 2020 increased 9.7% from the prior year reaching $4.1 trillion dollars. This increase was much higher than the 4.3% rate increase between 2018 and 2019 and considered to be largely attributed to federal expenditures in response to the COVID-19 pandemic. Limited information exists on costs attributed to the pandemic as response continues. The objective of this study was to understand hospitalization costs attributed to COVID-19 within the Veterans Administration (VA) and Department of Defense (DoD). METHODS: Data on hospitalizations within the VA and DoD with a primary diagnosis of COVID-19 were investigated to understand differences in total cost, cost per day, and length of stay by location, age, sex, and Medicare Severity Diagnosis Related Groups (MS-DRGs). 7,818 hospitalizations occurred at VA facilities, while 773 occurred at DoD facilities. 74.7% of the hospitalizations were attributed to respiratory infections and inflammation with major complication or comorbidity (MS-DRG 177).Generalized linearmodels using a gamma distribution for total cost and cost per day and Poisson distribution for length of stay were run to investigate outcomes of overall and byMS-DRG.RESULTS: In the full sample, cost did not differ by location (VA vs. DoD) or sex, however, those aged 71-76 cost on average $537 more than those ages 19-59 (537.67, 95%CI 34.67,1029.68). Length of stay was nearly 3 days shorter for DoD hospitalizations (-2.99, 95%CI -3.54,-2.34) and length of stay increased as age increased with those 77 years and older staying over 8 days longer than those aged 19-59 (8.70, 95%CI 5.04, 12,35). Total costs per day were lower for hospitalizations at DoD facilities (-521.96, 95%CI -718.40,-325.51) and for those aged 77 and above compared to those aged 19- 59 (-317.41, 95%CI -478.61,-156.21). Similar patterns existed when hospitalizations were stratified by MS- DRG, except that in hospitalizations for respiratory infections and inflammation with major complication or comorbidity total costs were $730 higher at DoD compared to the VA (729.99, 95%CI 296.53,1163.47) despite the cost per day remaining lower for DoD (-574.87, 95%CI -804.07,-345.68). CONCLUSIONS: Overall, total costs for hospitalizations from COVID-19 were similar at VA and DoD locations, however, length of stay and costs per day were lower for DoD. When investigating only hospitalizations with major complications or comorbidity, total costs were higher for the DoD, but length of stay and cost per day remained lower compared to the VA. Differences existed by age but not by sex.

ACUTE REPERFUSION TREATMENT DURING THE COVID-19 PANDEMIC: FINDINGS FROM SHANGHAI STROKE SERVICE SYSTEM

Background and aims: COVID-19 pandemic is affecting triage of strokes in emergency. We aimed to find whether COVID-19 delayed the reperfusion treatment in acute ischemic stroke (AIS) patients. Methods: The Shanghai Stroke Service System (4S) is a regional network that prospectively registries AIS patients within 7 days. Data with COVID- 19 negetive was extracted from January 2018 to December 2020. Compared to quality measures in 2018-2019, the performance during COVID- 19 outbreak (mainly during 1st quarter of 2020) and post were analyzed. The primary outcome was door to needle time (DTN). The secondary outcomes included the rate of reperfusion treatment and hospitalization cost. Results: Our study included 69,258 patients from 64 stroke centers. During 1st quarter 2018 to 4th quarter 2019, there was an overall downward trend of DTN (P trend=0.006). However, during 1st and 2nd quarters 2020, there was a significant delay of DTN. After outbreak in China, the average DTN plus mandatory COVID-19 PCR test dropped back to <60 minutes. The drop of reperfusion rate was also associated to COVID-19 outbreak (57.92% pre vs 51.74% during, P<0.001), while improved after, compared to those of previous(57.92% pre vs 62.32% post, P<0.001). The cost was slightly declined in 1st quarter 2020 (-$125 USD), which reflected changes in reperfusion rates. Conclusions: In 2020, COVID-19 pandemic prolonged the DTN during COVID-19 outbreak but improved after in Shanghai. Although the prevention protocol and PCR test are still in place, acute stroke care in Shanghai has back to normal post pandemic. (Figure Presented).

POSB103 COVID-19 Positive Patients Hospital Management in the Italian Setting: The Economic Impact

Objectives: To investigate the costs related to COVID-19 patients’ hospital management (from positivity confirmation to discharge, including rehabilitation activities), defining overall resources’ absorption with regard to both the COVID-19 per day and the COVID-19 clinical pathway costs, based on the patients’ clinical condition. Methods: A time-driven activity-based costing approach was implemented to define the costs related to the hospital management of COVID-19 positive patients, according to real-word data derived from six Italian Hospitals, in 2020. The average per-day cost and the average most frequent clinical pathways (considering the internal transfers between wards, based on the patient’s clinical improvement or deterioration), were valorised according to: 1) low-complexity hospitalizations;2) medium-complexity hospitalizations, with presence of hospital beds equipped with C-PAP or non-invasive ventilation;3) high-complexity hospitalizations. Results: The higher the complexity of care, the higher the hospitalization cost per day (low-complexity=€475.86;medium-complexity=€700.20;high-complexity=€1,401.65). Focusing on the entire clinical pathway (ER access, ward transfer, and rehabilitation): i) 29% spent 18.6 days between a medium and a low-complexity hospitalization (€10,778);ii) 16% spent 17.7 days between a low and a medium-complexity hospitalization (€13,902);iii) 12% spent 22.6 days between a high and a medium-complexity hospitalization (€25,817);iv) 8% spent 23.4 days between a medium and a high-complexity hospitalization (€32,141) and v) 5% spent 18.4 days between a low and a high-complexity hospitalization (€23,431). 30% of patients did not experience any ward’s transfer: 17% spent 10.2 within a medium-complexity hospitalization, 9% spent 13 days within a low-complexity hospitalization and 4% spent 11 days within a high-complexity hospitalization, requiring on average €10,113, €6,198 and €21,346 respectively for their management. Conclusions: The study reported the economic evaluation of COVID-19 pandemic in Italy, providing real-world data for an adequate healthcare resources’ allocation, being useful for the further development of proper reimbursement tariffs devoted to COVID-19 positive hospitalized patients.