Abstract 13412: Electronic Consultation for the Management of Atrial Fibrillation is Associated With Higher Healthcare Costs

Introduction: A study of 42,000 cardiology consults within the Veterans Health Administration (VHA) in 2016 found that patients who received electronic consultation (e-consults) had similar healthcare costs at 6 months compared to those who received face-to-face (F2F) consults. However, results may have been confounded if patients with less costly conditions received e-consults. Our aim was to compare costs between those receiving F2F vs. e-consults for a similar indication. Hypothesis: Electronic rather than F2F consultation for atrial fibrillation (AF) management will be associated with lower total healthcare costs. Methods: We conducted a retrospective cohort study of a national sample of VHA patients who received cardiology consultation in 2016. We used a natural language processing script to identify consults for AF management. Primary outcomes were total healthcare costs at 3 and 6 months. Secondary outcomes included inpatient and outpatient costs. We compared costs between groups using a generalized linear model with a gamma distribution and log link. We adjusted for community wage and Charlson comorbidity indices, distance to nearest facility, age, and gender. Standard errors were clustered at the facility level. Results: We sampled 176 F2F and 136 e-consults from 43 facilities. Mean total 6-month costs were $12,928 (95% confidence interval [CI]: 1,377; 40,644) and $8,286 (95% CI: 959; 31,320) among e-consult and F2F groups, respectively. The e-consult group had 12.3% higher 3-month (p<0.001) and 41.5% higher 6-month total healthcare costs (p<0.001) in comparison to the F2F group. At 3 months, the e-consult group had 25.1% lower inpatient costs (p<0.001) and 32.5% higher outpatient costs (p<0.001). At 6 months, the e-consult group had 6.3% higher inpatient costs (p<0.001) and 48.4% higher outpatient costs (p<0.001). Conclusions: Use of e-consults for AF management is associated with reduced inpatient costs at 3 months, but higher total costs, which were largely driven by outpatient costs. Improving our understanding of healthcare utilization after initial consultation, or in differences in reasons for consultation within AF management may help explain these differences.

49. Clinical Utility of Oseltamivir Restriction Policy

Background Inappropriate use of oseltamivir and antibiotics for upper respiratory tract infections may increase risk of microbial resistance. Restriction policies have been used to curtail inappropriate use of oseltamivir and antimicrobials in suspected or confirmed influenza patients. We assessed the impact of Infectious Diseases (ID) consult on the management of oseltamivir and concomitant antibiotics. Methods A single-center, retrospective study of patients ≥ 17 years, admitted for greater than 24 hours who received oseltamivir from October 1, 2018 to May 1, 2019 were evaluated. Demographics, Charlson Weighted Index of Comorbidity (CWIC), length of hospital stay (LOS), discharge disposition, rapid flu test, respiratory viral panel, sputum and blood cultures, antibiotic regimen and duration were collected. Continuous variables were analyzed using Students t-test and categorical variables with Chi square test. Results 298 patients were screened and 182 patients met the inclusion criteria. Please see table below for results. Oseltamivir was appropriately continued in 92.9% in the ID consult group compared to 89.3% in the non-ID consult group (p = 0.51). Antibiotic interventions were appropriate in 63.2% of the ID consult group compared to 40% in non-ID group (p = 0.36). Results Summary Conclusion Oseltamivir interventions were appropriate and similar in between groups. Further, there was higher percentage of appropriate antibiotic interventions in the ID physician group. Duration of antibiotics was longer in the ID physicians consulted group which may be due to higher severity of illness in the group. Disclosures All Authors: No reported disclosures

Community Tourism Development in Viet Hai Commune (Cat Ba, Hai Phong City, Viet Nam) Under the Green Economy Model

The study of community tourism development based on green economy model is the focus of this paper. The research is implemented in Viet Hai - a commune of Cat Hai island district, Hai Phong city, Vietnam. In order to evaluate, select and develop this model in the locality, a number of research methods have been applied such as: Method of seminars, expert consult, group system of sampling methods, fertilizer analyzing laboratories and methods of interviewing and collecting socio-economic data. The research outcome is given that, the community tourism based on green economy is a type of economic model that contributes not only on the local socio-economic development, but also surmounting the seasonal tourism situation, and maximizing the region&#39;s potential and strengths. The model chosen was the communitys based tourism model, with the participation of 1/3 of households in Viet Hai commune. The model has a management board with applicable rules and regulations to objects such as households, tourism operators and Viet Hai visitors. The model has been oriented towards exploiting the landscape values associated with environmental protection programs, especially towards the point-based community tourism model of Cat Ba district &ndash; which say &ldquo;no&rdquo; to single-use plastic products. This tourism model has created the tourism products that are different from the existing models in Cat Ba (Hai Phong), creating channels to link with tourists to attract more visitors to Viet Hai increasingly to the year.

SUN-LB16 Clitoromegaly in Premature Infants: Is It Truly Pathologic?

Background: Normative data for clitoral size in premature infants are limited. Consequently, the potential for over-diagnosis is high; leading to unnecessary investigations, increased healthcare costs and parental stress. Several proposed mechanisms, e.g., persistence of fetal adrenal zone activity to term gestation, point to the transient physiologic nature of clitoromegaly in premature infants. Studies of normative data have shown a negative correlation between birth weight and clitoral size. We hypothesized that 1) the majority of clitoromegaly in premature infants is not associated with hormonal dysfunction and 2) lower birth weight and lower gestational age increase the likelihood of a formal consult in premature infants with perceived clitoromegaly. Methods: A retrospective chart review of female infants born at our institution from January 2012 to December 2018 with perceived clitoromegaly was conducted. Birth history, demographic and laboratory data were collected. Patients were divided into two groups: ‘formal consult’ and ‘no formal consult’ for clitoromegaly. True clitoromegaly was defined as clitoral length &gt;9 mm or clitoral width &gt;6 mm. Patients not meeting these criteria or those with clitoral edema, prominent clitoral hood were classified under false clitoromegaly. In the ‘no formal consult’ group, the documented discharge examination was used to assess persistence of clitoromegaly. Uni- and multi-variable logistic regression were used to determine factors that increased the likelihood of a formal consult. Results: 29 patients met inclusion criteria; 15 in the ‘formal consult’ group and 14 in the ‘no formal consult’ group. No significant differences were found between the groups in terms of birth weight, gestational age, race, ethnicity and maternal factors. History of IUGR (intrauterine growth restriction) was more common in the ‘formal consult’ group (60%) vs. ‘no formal consult’ group (21%) (p=0.04). Only 3/15 patients in the ‘formal consult’ group had true clitoromegaly; all 3 had normal 17-hydroxyprogesterone levels, and only 1 patient had transient elevation in androgen levels (androstenedione, deoxycortisol and testosterone). Of the ‘no formal consult’ group, only 3/14 patients had clitoromegaly noted on discharge; outcome was unknown for 1. Multi-variable logistic regression showed that lower gestational age (p=0.04) and history of IUGR (p=0.03), even after adjusting for birth weight, increased the likelihood of a formal consult. Conclusion: In summary, the majority of perceived clitoromegaly in premature infants is not associated with hormonal dysfunction. Lower gestational age and a history of IUGR increase the likelihood of a formal consult for clitoromegaly in these patients. Approximately half of the patients were noted to have false clitoromegaly indicating inconsistencies in examination technique and need for provider education.

Running a mentalization-based treatment (MBT) programme within a public community adult mental health service setting: a feasibility study

Objectives:This article aimed to address the feasibility of mentalization-based treatment (MBT) for patients with personality disorder in a non-specialist setting. The development and implementation of an MBT Programme is described.Methods:A multidisciplinary Consult Group met to plan the implementation of the programme. Participants attended a psychoeducation group (MBT Introductory Group), then weekly individual and group therapy. Fourteen participants started the full programme with eight completing at least 9 months, complete data are available for five participants who completed 27 months (first cohort) and 21 months (second cohort). Data include quantitative measures and qualitative questionnaires/interviews. All had a diagnosis of personality dysfunction with co-morbid disorder including anxiety/depressive disorder, post-traumatic stress disorder and eating disorder.Results:Data on five participants revealed reductions in global level of distress, improvements in psychological well-being, less interpersonal difficulties and better work and social functioning. Qualitative data from feedback questionnaires (n = 18) and in-depth interview (n = 2) are discussed under the themes of mentalizing, treatment feedback/outcomes and group factors. Therapist reflections on the process identify the challenges involved in implementing a specialist psychotherapy programme within a general service and learning points from this are discussed.Conclusions:MBT is an acceptable treatment for patients with personality dysfunction. Prior to the implementation of a programme, factors at the therapist, team and organizational level, as well as the wider context, need to be examined. This is to ensure that conditions are in place for proper adherence to the model to achieve the positive outcomes demonstrated in the RCT studies.

Impact of Infectious Diseases Consultation on Mortality in Patients with Candidemia

Background An infectious diseases (ID) consultation is often, but not always, obtained to help guide treatment of patients with candidemia. We examined if ID consultation affected patient outcome in patients with culture positive candidemia. Methods We assembled a retrospective cohort of 1,873 cases of candidemia in patients hospitalized in our academic tertiary care hospital from 2002 to 2015. We collected data on comorbidities, predisposing factors; antifungal therapy, survival and ID consult. Patients who died within 24 hours of diagnosis were excluded, under the presumption that they did not have an opportunity to receive an ID consult. Survival analysis was performed via univariate and multivariate Cox Regression with censoring at 90 days, as subsequent mortality was less likely to be related to candidemia. Results 913 (49%) of the candidemic patients received an ID consult; 960 (51%) did not. Underlying comorbidities were evenly distributed between patients with and without an ID consult, except that patients with an ID consult more frequently had a central line (39% vs. 26%, p &lt; 0.001), were on mechanical ventilation (4% vs. 2%, P = 0.003) or were receiving extracorporeal membrane oxygenation (2.2% vs. 0.5%, p = 0.002). The ID consult group had lower 90-day mortality compared with patients without an ID consult (34% vs. 49%, P &lt; 0.001), with an adjusted hazard ratio of mortality for those patients receiving an ID consult of 0.55 (95% CI: 0.48, 0.64, P &lt; 0.001) (Fig 1). Patient management differed significantly: the ID consult group was more likely to receive an echinocandin (29% vs. 21%, P &lt; 0.001) or amphotericin B (AmB) (3.4% vs. 1.4%, P = 0.006). Conclusion Candidemic patients who received an ID consult were significantly less likely to die, and were more likely to receive therapy with amphotericin or an echinocandin. These data suggest that an ID consult should be an integral part of clinical care of patients with candidemia. Disclosures W. Powderly, Merck: Grant Investigator and Scientific Advisor, Consulting fee and Research grant; Gilead: Scientific Advisor, Consulting fee; Astellas: Grant Investigator, Research grant; A. Spec, Astellas Pharma US, Inc.: Grant Investigator, Research grant

Psychiatric Consultations with Depressed Medical Inpatients: A Randomized Controlled Cost-Effectiveness Study

Nonspecific, supportive psychiatric consultations were performed with a random sample of thirty-three general medical inpatients scoring thirteen or more on the Beck Depression Inventory. The control group consisted of thirty-five patients, matched for sex, marital status, somatic history, and seriousness of illness. The number of patients receiving no analgesic and/or psychotropic medication in the consult group (39%) was significantly greater than that in the control group (17%). When compared with their mean BDI score on admission, the BDI score just before discharge had decreased significantly in the consult group (from 20 to 13), but not in the control group (from 19 to 16). Probably because the patient sample was too heterogeneous, with too low a prevalence of mental disorders (45%), a significant reduction in other medical care expenditures and in length of hospital stay could not be demonstrated.