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246 Empiric Antiretroviral Therapy for Acute HIV Infection in the Emergency Department
Research Forum Abstracts
246
Empiric Antiretroviral Therapy for Acute HIV Infection in the Emergency Department
Stanley K, Arora S, Klonoff A, Lora M, Menchine M, Merjavy S, Walsh K, Jacobson K/USC Keck School of Medicine, Los Angeles, CA; USC Keck School of Medicine, Los Angeles, CA; USC Keck School of Medicine, Los Angeles, CA
Study Objectives: The acute phase of HIV infection is a highly transmissible phase and responsible for a disproportionate amount of new HIV infections. During this phase, individuals have non-specific viral symptoms, high viral loads, and the HIV virus itself is more virulent, which is more conducive to virus transmission than in chronic HIV infection. A key to controlling the spread of HIV is identifying acute HIV infection early and getting newly infected individuals to alter their behavior and start antiretroviral therapy (ART) immediately. The objective of this study is to determine the feasibility and willingness of patients with suspected acute HIV infection to begin empiric antiretroviral therapy in the emergency department. Methods: Since 2011, over 68,000 patients have been tested for HIV in our nontargeted screening program in a large urban emergency department (ED). In this screening program, 852 HIV positive patients have been identified, of which 274 patients were newly diagnosed as HIV positive in the ED. An HIV specialist evaluates all patients who are newly diagnosed with HIV in real time in the emergency department. In December 2014, in conjunction with HIV specialists, we began offering ART to individuals with likely acute infection if they had: 1) a clinical history consistent with acute HIV infection 2) Negative HIV test in the last 6-12 months 3) No co-morbid conditions with risks that outweigh the benefits of treatment 4) 4th generation positive HIV test with pending HIV 1/2 antibody test and HIV viral load by PCR 5) Stable baseline CBC and chemistry panel in the ED 6) Genotype and CD4 can be ordered in ED and 7) Patient understands and/or agrees to: a) confirmatory tests b) take medication c) commit to abstinence or 100% condom use d) notify partners e) a follow-up appointment and f) provide reliable personal contact information (phone number/email address). Results: From December 1, 2014 to October 1, 2015, there have been 14 confirmed cases of acute HIV infection in our ED screening program. Of these, nine of the cases were identified in the ED in real time as likely acute HIV using the aforementioned criteria. All nine were offered and agreed to empiric ART in the ED after evaluation by an HIV specialist. One patient withdrew prior to starting ART. The other eight patients were prescribed ART in the ED. Eight of the nine patients suspected to be acutely infected were ultimately confirmed to be acutely infected with HIV and one patient was chronically infected. There were no false positive tests. Conclusion: Prescribing empiric ART in the ED for acute HIV infection is feasible and well received by patients. This novel approach using 4th generation immunoassays and empiric ART facilitates urgent HIV intervention, which can lead to an expanded ED role in the HIV care continuum.
3-10 years old with a male predominance. The predominant race in all groups is Black, followed by Hispanic and White, with a large proportion of patients in group 5 being Black (65.5%). Cluster 1 (62% of patients) shows the lowest rates of acute care use. No child in cluster 1 was hospitalized for asthma. They used the ED for asthma only once (66.2%) and had moderate levels of ED use for other conditions. They were least likely to have a mental health-related discharge diagnosis, and were less likely to have visited multiple facilities, with 38.9% receiving care at only one. Cluster 2 (19% of patients) showed a pattern of low asthma ED visits and one-time hospitalizations. Almost half (47.7%) had no asthma ED visits with low rates of care received for other conditions. Cluster 3 (11% of patients) had high rates of ED visits, both for asthma and other diagnoses. About two thirds had 5 or more asthma (68.5%) and non-asthma (65.8%) ED visits. Despite high rates of ED use, hospitalization for asthma and other conditions was rare. This group had the highest rate of multiple facility use; almost 31.5% received care at all 3 facilities. Cluster 4 (7% of patients) had moderate ED use for both asthma and other illnesses, with higher rates of asthma hospitalizations compared to cluster 1 with similar levels of ED use. Nearly one-quarter (24.4%) had received care at all 3 facilities, and one in 10 had a mental health diagnosis. Cluster 5 (n¼29) had the highest overall rates of acute care use. Almost half (48.3%) had been hospitalized for asthma within 30 days of a prior asthma-related hospitalization. One in 7 (13.8%) had a mental health diagnosis. Conclusion: Though our clusters were constructed around asthma-related acute care use, we observed differences between groups across multiple socio-behavioral factors, suggesting these clusters may represent children who differ not on disease severity alone but along multiple dimensions with implications for optimal asthma care and overall health. Tailoring interventions to these differences, as well as disease severity, may be more effective in keeping asthmatic children healthy and reducing avoidable acute care use.
EMF
247
Cluster Analysis of Acute Care Utilization Yields Insights for Tailored Pediatric Asthma Interventions
Abir M, Truchil A, Wiest D, Goldstick J, Nelson D, Koegel P, Lozon M, Choi H, Brenner J/University of Michigan, Ann Arbor, MI; Camden Coalition of Healthcare Providers, Camden, NJ; University of Michigan, Ann Arbor, NJ; RAND Corporation, Santa Monica, NJ
Study Objective: To understand patterns of pediatric asthma-related acute care use to inform interventions to reduce avoidable hospitalizations. Methods: Analysis is based on 2010-2014 all-payer claims data from two hospitals and a freestanding emergency department (ED). Cluster analysis was performed to classify patients aged 0-17 through two variables total asthma-related ED visits and total asthma-related hospitalizations. Patient typologies were generated using a Ward’s Method with Squared Euclidean Distance hierarchical clustering procedure. After determining the optimal solution, clusters were compared based on demographics, non-asthma-related ED visits and hospitalizations, 30-day return ED visits and asthma readmissions, mental health comorbidity prevalence, use of different acute care facilities, and Medicaid status. Results: 3,170 children met inclusion criteria. Cluster analysis showed 5 typologies of patients with distinct asthma-related acute care use, socio-behavioral and health characteristics. In all groups more than half of the children were between the ages of
S96 Annals of Emergency Medicine
EMF
248
A Patient-Centered Approach to Observation Care and Transitions Home
Trivedi A, Gentsch A, Jennings E, Hudgins A, Gerolamo A, Rising K/Thomas Jefferson University Hospital, Philadelphia, PA; Rutgers University, New Brunswick, NJ
Study Objectives: Patients are frequently placed in observation for evaluation of chest pain, yet little is known about patients’ understanding of observation care and their primary goals and needs during their stay. Our goal was to engage patients during an observation unit stay for evaluation of chest pain to assess the needs with which they arrived at the hospital, the care they had received thus far, and their anticipated needs and goals upon discharge home. Methods: We performed qualitative semi-structured interviews of patients placed in the observation unit for evaluation of chest pain. Key questions focused on driving factors that brought them to the hospital, perspectives on being placed in the observation unit, assessment of their health status, and anticipated upon discharge
Volume 68, no. 4s : October 2016
246
Empiric Antiretroviral Therapy for Acute HIV Infection in the Emergency Department
Stanley K, Arora S, Klonoff A, Lora M, Menchine M, Merjavy S, Walsh K, Jacobson K/USC Keck School of Medicine, Los Angeles, CA; USC Keck School of Medicine, Los Angeles, CA; USC Keck School of Medicine, Los Angeles, CA
Study Objectives: The acute phase of HIV infection is a highly transmissible phase and responsible for a disproportionate amount of new HIV infections. During this phase, individuals have non-specific viral symptoms, high viral loads, and the HIV virus itself is more virulent, which is more conducive to virus transmission than in chronic HIV infection. A key to controlling the spread of HIV is identifying acute HIV infection early and getting newly infected individuals to alter their behavior and start antiretroviral therapy (ART) immediately. The objective of this study is to determine the feasibility and willingness of patients with suspected acute HIV infection to begin empiric antiretroviral therapy in the emergency department. Methods: Since 2011, over 68,000 patients have been tested for HIV in our nontargeted screening program in a large urban emergency department (ED). In this screening program, 852 HIV positive patients have been identified, of which 274 patients were newly diagnosed as HIV positive in the ED. An HIV specialist evaluates all patients who are newly diagnosed with HIV in real time in the emergency department. In December 2014, in conjunction with HIV specialists, we began offering ART to individuals with likely acute infection if they had: 1) a clinical history consistent with acute HIV infection 2) Negative HIV test in the last 6-12 months 3) No co-morbid conditions with risks that outweigh the benefits of treatment 4) 4th generation positive HIV test with pending HIV 1/2 antibody test and HIV viral load by PCR 5) Stable baseline CBC and chemistry panel in the ED 6) Genotype and CD4 can be ordered in ED and 7) Patient understands and/or agrees to: a) confirmatory tests b) take medication c) commit to abstinence or 100% condom use d) notify partners e) a follow-up appointment and f) provide reliable personal contact information (phone number/email address). Results: From December 1, 2014 to October 1, 2015, there have been 14 confirmed cases of acute HIV infection in our ED screening program. Of these, nine of the cases were identified in the ED in real time as likely acute HIV using the aforementioned criteria. All nine were offered and agreed to empiric ART in the ED after evaluation by an HIV specialist. One patient withdrew prior to starting ART. The other eight patients were prescribed ART in the ED. Eight of the nine patients suspected to be acutely infected were ultimately confirmed to be acutely infected with HIV and one patient was chronically infected. There were no false positive tests. Conclusion: Prescribing empiric ART in the ED for acute HIV infection is feasible and well received by patients. This novel approach using 4th generation immunoassays and empiric ART facilitates urgent HIV intervention, which can lead to an expanded ED role in the HIV care continuum.
3-10 years old with a male predominance. The predominant race in all groups is Black, followed by Hispanic and White, with a large proportion of patients in group 5 being Black (65.5%). Cluster 1 (62% of patients) shows the lowest rates of acute care use. No child in cluster 1 was hospitalized for asthma. They used the ED for asthma only once (66.2%) and had moderate levels of ED use for other conditions. They were least likely to have a mental health-related discharge diagnosis, and were less likely to have visited multiple facilities, with 38.9% receiving care at only one. Cluster 2 (19% of patients) showed a pattern of low asthma ED visits and one-time hospitalizations. Almost half (47.7%) had no asthma ED visits with low rates of care received for other conditions. Cluster 3 (11% of patients) had high rates of ED visits, both for asthma and other diagnoses. About two thirds had 5 or more asthma (68.5%) and non-asthma (65.8%) ED visits. Despite high rates of ED use, hospitalization for asthma and other conditions was rare. This group had the highest rate of multiple facility use; almost 31.5% received care at all 3 facilities. Cluster 4 (7% of patients) had moderate ED use for both asthma and other illnesses, with higher rates of asthma hospitalizations compared to cluster 1 with similar levels of ED use. Nearly one-quarter (24.4%) had received care at all 3 facilities, and one in 10 had a mental health diagnosis. Cluster 5 (n¼29) had the highest overall rates of acute care use. Almost half (48.3%) had been hospitalized for asthma within 30 days of a prior asthma-related hospitalization. One in 7 (13.8%) had a mental health diagnosis. Conclusion: Though our clusters were constructed around asthma-related acute care use, we observed differences between groups across multiple socio-behavioral factors, suggesting these clusters may represent children who differ not on disease severity alone but along multiple dimensions with implications for optimal asthma care and overall health. Tailoring interventions to these differences, as well as disease severity, may be more effective in keeping asthmatic children healthy and reducing avoidable acute care use.
EMF
247
Cluster Analysis of Acute Care Utilization Yields Insights for Tailored Pediatric Asthma Interventions
Abir M, Truchil A, Wiest D, Goldstick J, Nelson D, Koegel P, Lozon M, Choi H, Brenner J/University of Michigan, Ann Arbor, MI; Camden Coalition of Healthcare Providers, Camden, NJ; University of Michigan, Ann Arbor, NJ; RAND Corporation, Santa Monica, NJ
Study Objective: To understand patterns of pediatric asthma-related acute care use to inform interventions to reduce avoidable hospitalizations. Methods: Analysis is based on 2010-2014 all-payer claims data from two hospitals and a freestanding emergency department (ED). Cluster analysis was performed to classify patients aged 0-17 through two variables total asthma-related ED visits and total asthma-related hospitalizations. Patient typologies were generated using a Ward’s Method with Squared Euclidean Distance hierarchical clustering procedure. After determining the optimal solution, clusters were compared based on demographics, non-asthma-related ED visits and hospitalizations, 30-day return ED visits and asthma readmissions, mental health comorbidity prevalence, use of different acute care facilities, and Medicaid status. Results: 3,170 children met inclusion criteria. Cluster analysis showed 5 typologies of patients with distinct asthma-related acute care use, socio-behavioral and health characteristics. In all groups more than half of the children were between the ages of
S96 Annals of Emergency Medicine
EMF
248
A Patient-Centered Approach to Observation Care and Transitions Home
Trivedi A, Gentsch A, Jennings E, Hudgins A, Gerolamo A, Rising K/Thomas Jefferson University Hospital, Philadelphia, PA; Rutgers University, New Brunswick, NJ
Study Objectives: Patients are frequently placed in observation for evaluation of chest pain, yet little is known about patients’ understanding of observation care and their primary goals and needs during their stay. Our goal was to engage patients during an observation unit stay for evaluation of chest pain to assess the needs with which they arrived at the hospital, the care they had received thus far, and their anticipated needs and goals upon discharge home. Methods: We performed qualitative semi-structured interviews of patients placed in the observation unit for evaluation of chest pain. Key questions focused on driving factors that brought them to the hospital, perspectives on being placed in the observation unit, assessment of their health status, and anticipated upon discharge
Volume 68, no. 4s : October 2016