Abstract 16382: The Surface ECG May Provide Information About Left Ventricular Systolic Function in Patients With Right Bundle Branch Block

Introduction: In patients (pts) with right bundle branch block (RBBB) and heart failure, assessment of left ventricular (LV) function is vital to management, but echocardiograms (ECHO) may not always be readily available. We studied the utility of using the Superimposed Median Format (available on digital ECG systems) in assessing LV function. This format allows visual recognition of change in dV/dT when rapid initial impulse propagation over the left bundle branch (LBB) and LV Purkinje network transitions to slower muscle-to-muscle propagation to the right ventricle (RV) in the setting of RBBB. Hypothesis: With a normal LBB and healthy LV myocardium, the transition from rapid forces to slower depolarization would occur in the 1 st half of the QRS complex ( Early Transition Group - ET) whereas in patients with abnormal LV function, this transition would occur in the 2 nd half (Late Transition Group - LT) of the QRS complex. Methods: Digital superimposed median format ECGs of 108 pts with RBBB were analyzed. Pts were divided into 2 groups: ET or LT. See figure. LVEFs were obtained from ECHO. LVEF ≥ 50% was considered normal. Results: ET: n = 69. LT: n = 39. Mean QRS durations were not different in the 2 groups. ET pts were more likely to have normal LVEF (p < 0.01). See figure. PPV of ET in predicting LVEF ≥50% = 90%; NPV = 71%. Accuracy = 82%. Conclusions: These data, if confirmed, suggest that in pts with RBBB, visual analysis of the QRS complex from the surface ECG using the superimposed median format may provide valuable clues about LV systolic function, and may be clinically useful when ECHO are not readily available.

The clinical spectrum of hydrocephalus in adults: report of the first 517 patients of the Adult Hydrocephalus Clinical Research Network registry

OBJECTIVEThe authors describe the demographics and clinical characteristics of the first 517 patients enrolled in the Adult Hydrocephalus Clinical Research Network (AHCRN) during its first 2 years.METHODSAdults ≥ 18 years were nonconsecutively enrolled in a registry at 6 centers. Four categories of adult hydrocephalus were defined: transition (treated before age 18 years), unrecognized congenital (congenital pattern, not treated before age 18 years), acquired (secondary to known risk factors, treated or untreated), and suspected idiopathic normal pressure hydrocephalus (iNPH) (≥ age 65 years, not previously treated). Data include etiology, symptoms, examination findings, neuropsychology screening, comorbidities, treatment, complications, and outcomes. Standard evaluations were administered to all patients by trained examiners, including the Montreal Cognitive Assessment, the Symbol Digit Modalities Test, the Beck Depression Inventory–II, the Overactive Bladder Questionnaire Short Form symptom bother, the 10-Meter Walk Test, the Boon iNPH gait scale, the Lawton Activities of Daily Living/Instrumental Activities of Daily Living (ADL/IADL) questionnaire, the iNPH grading scale, and the modified Rankin Scale.RESULTSOverall, 517 individuals were enrolled. Age ranged from 18.1 to 90.7 years, with patients in the transition group (32.7 ± 10.0 years) being the youngest and those in the suspected iNPH group (76.5 ± 5.2 years) being the oldest. The proportion of patients in each group was as follows: 16.6% transition, 26.5% unrecognized congenital, 18.2% acquired, and 38.7% suspected iNPH. Excluding the 86 patients in the transition group, who all had received treatment, 79.4% of adults in the remaining 3 groups had not been treated at the time of enrollment. Patients in the suspected iNPH group had the poorest performance in cognitive evaluations, and those in the unrecognized congenital group had the best performance. The same pattern was seen in the Lawton ADL/IADL scores. Gait velocity was lowest in patients in the suspected iNPH group. Categories that had the most comorbidities (suspected iNPH) or etiologies of hydrocephalus that directly cause neurological injury (transition, acquired) had greater degrees of impairment compared to unrecognized congenital, which had the fewest comorbidities or etiologies associated with neurological injury.CONCLUSIONSThe clinical spectrum of hydrocephalus in adults comprises more than iNPH or acquired hydrocephalus. Only 39% of patients had suspected iNPH, whereas 43% had childhood onset (i.e., those in the transition and unrecognized congenital groups). The severity of symptoms and impairment was worsened when the etiology of the hydrocephalus or complications of treatment caused additional neurological injury or when multiple comorbidities were present. However, more than half of patients in the transition, unrecognized congenital, and acquired hydrocephalus groups had minimal or no impairment. Excluding the transition group, nearly 80% of patients in the AHCRN registry were untreated at the time of enrollment. A future goal for the AHCRN is to determine whether patients with unrecognized congenital and acquired hydrocephalus need treatment and which patients in the suspected iNPH cohort actually have possible hydrocephalus and should undergo further diagnostic testing. Future prospective research is needed in the diagnosis, treatment, outcomes, quality of life, and macroeconomics of all categories of adult hydrocephalus.

Utilizing serum bicarbonate instead of venous pH to transition from intravenous to subcutaneous insulin shortens the duration of insulin infusion in pediatric diabetic ketoacidosis

Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children’s hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.

Healthcare Utilization Patterns and Health Quality Indicators in Sickle Cell Disease Patients Transitioning from Pediatric to Adulthood

Introduction: Due to improvements in comprehensive medical care, data suggests that about 93% of children born with sickle cell disease (SCD) are now living past 18 years of age. Young adulthood is a high-risk time for clinical complications and progressive SCD-related organ damage. The majority of SCD-related deaths occur after 18 years of age and after transfer to an adult provider, which leaves this population particularly vulnerable to poor outcomes. In addition, current research suggests that this transition period is associated with increased health care utilization (HCU), and thus, highlights the need for proper care models for transitioning SCD patients. This study aims to describe the pattern of HCU and health quality indicators (HQI) in SCD patients at different ages of the transition period. Methods: A retrospective data analysis of health insurance claims from a single health plan for service dates 04/01/2016 through 03/31/2017 was conducted. Members meeting the claims-based definition of SCD (those with any sickle cell related ICD 9/10 CM diagnosis code on at least two separate encounters on distinct dates during the study period) with 12 months of continuous membership were included in the initial sample. Those within this sample that are 11-35 years old were selected and further stratified into three groups representing pre-transition (Group A: 11-18 yr.), transition (Group B: 19-26 yr.), and adult (Group C: 27-35 yr.). Data obtained include demographics, HCU patterns (emergency department (ED) visits, frequency of acute inpatient admissions and diagnosis, 30-day readmission rate and total cost of care), and HQI (hydroxyurea (HU) use, influenza (Flu) vaccination status, and total cost and number of visits for PCP and specialists). Two specific metrics of utilization included in the analysis were emergency department reliance ratio (EDR) and calculated HU medication possession ratio (MPR). EDR was calculated as the sum total of all ED visits divided by the total number of ambulatory visits. An EDR ≥ 0.33 was considered an indicator of excessive reliance. MPR was calculated as total days of HU prescription divided by the difference between the number of days of insurance enrollment and the number of days hospitalized. MPR of 1.0 was considered complete adherence. Results: A total of 144 members, 88 (61%) female, fit the inclusion criteria. Member number was similarly distributed in all groups: A: 50, B: 48, and C: 46. Medicaid was the primary insurance for 123 (85%) patients, followed by Commercial 15 (10%), and Medicare 6 (5%). While average total cost of care was similar in the three groups (A: $22,688; B: $25,525 and C: $25,873) average cost of ED visits was three times more for Group C: $2,153 as compared with A: $862 and B: $954. As shown in table 1, an increase in EDR, acute inpatient admission cost, and readmission rate was noted between groups A and B. Moreover, although Group C represented older patients, their ED utilization, EDR, and readmission rate were comparable with that of Group B. Analysis of HQI showed that almost half (44%) of the patients in Group A had no ED visits during the study period as compared to 29% of Group B and 26% of Group C. Of note, Group C had a higher number of 10 or more ED visits (n=9; range 10- 63 visits) compared to Group B (n=2; range 1-14) and Group A (n=1). More than 50% of patients in Groups B and C did not have a PCP or specialty visit within the study period vs. 25% in Group A. Group B had 13 visits to pediatric Heme/Onc providers, but no visits to adult Heme/Onc providers, even though the institutional maximum transition age is 21 years old. MPR was roughly 0.25 for each of the groups, and thus, consistent with poor adherence across all ages. Influenza vaccination was less frequent in the transition group (Group B) than in Groups A and C. Conclusion: Our data shows the vulnerability of SCD patients during their transition years (19-26 yr.) from pediatric to adulthood, thereby confirming the findings from prior studies. These patients demonstrated higher HCU patterns (i.e. EDR, acute inpatient admission cost and readmission rate) and lower HQI (i.e. lack of PCP and Heme/Onc visits, lower Flu vaccinations, and MPR). Thus, this study highlights the urgent need of improved protocols and systems in order to provide continuity and quality care during these critical transition years. "The last two authors of this abstract contributed equally." Disclosures No relevant conflicts of interest to declare.

The Conundrum of Hydroxyurea Use and Health Care Utilization in Sickle Cell Disease

Introduction: Sickle cell disease (SCD) is a chronic condition associated with a decreased lifespan. Studies in adult and pediatric SCD populations have shown that hydroxyurea (HU) reduces the frequency and intensity of SCD painful events and decreases morbidity. Follow-up studies of MSH patients also showed cost effectiveness and improved survival for HU user. Adequate dosing and continuous daily adherence to HU use are necessary to achieve these benefits. The NIH Consensus Statement on HU Treatment for SCD had identified non-adherence as a major barrier to the effectiveness of HU therapy.The overarching aim of the study wasto describe the pattern of HCU and health quality indicators (HQI) in a SCD population at different ages of the transition period-data submitted in another abstract-. Here we present data supporting patterns of HU utilization and cost in three different SCD patient age-groups. Methods: We conducted a retrospective data analysis of health insurance claims from a single health plan for service dates 04/01/2016 through 03/21/2017. Members meeting the claims-based definition of SCD (those with any sickle cell related ICD 9/10 CM diagnosis code on two or more separate encounters on distinct dates during the study period) with 12 months of continuous membership were included in the analysis. Only members ages 11-35 years were selected based on study aims and then stratified into three groups representing pre-transition (Group A: 11-18 yr.), transition (Group B: 19-26 yr.), and adult (Group C: 27-35 yr.). Data obtained include demographics, utilization patterns such as: number and cost of Emergency Room (ED) visits, ED reliance rate and total cost of care. Health quality indicators (HQI) such as: hydroxyurea (HU) use, calculated HU medication possession ratio (MPR), influenza (Flu) vaccination status, and total cost and number of visits for PCP and specialists were also obtained. An ED ratio reliance ratio above 0.33 was considered an indicator of excessive reliance. HU medication possession ratio (MPR) of 1.0 was considered complete adherence Results: One hundred-fourty-four patients, 88 (61%) female, fit the inclusion criteria. Patient number was similarly distributed in all groups: A: 50, B: 48, and C: 46. Medicaid was the primary insurance for 123 (85%) patients, followed by Commercial 15 (10%), and Medicare 6 (5%). The % of HU prescription filled was less than 4 in all three groups, the younger patients -pre-transition group- had 37 % vs. 33% for each of the two group of older patients. HU medication possession ratio was similar and low for all three groups: A=.27, B=.26 and C=.28; 1.0. Those on HU independently of the age groups had a lower rates of both lower and Higher ED reliance rate than those not on HU. For those on HU, the older patients-group C- was the only one with increase of higher ED reliance with compared with those with lower ED reliance (A: 7 vs. 12; B: 5 vs. 7 and C: 9 vs. 4). The Total Cost of Care of the pre-transition group was similar ~$22,000 between those prescribed HU and those not on HU. The total cost of care was twice as much for those study subjects on HU than for those on group B and C ($44,941 and $42,633). Those not on HU in the groups B and C had the lower total care cost ($25,817 and $17,763). Conclusion: After 20 years of HU approval by the FDA as a disease modifying therapy for SCD, analysis of insurance data regarding HU use, adherence and cost of care in SCD patients before, during and after transition from Pediatric to adult care, still reveals poor adherence and higher overall total care cost but, and lower ED reliance. This Conundrum supports the needs further emphasis on increasing education towards use and adherence to HU therapy, while continuing to develop new therapeutic interventions towards disease modification and cure. Disclosures No relevant conflicts of interest to declare.