93 Identifying gaps in care associated with risk of recurrent asthma exacerbation following before medically advised discharge

Objectives/Goals: Discharges before medically advised (BMA) – also known as “against medical advice” – after an asthma exacerbation are associated with adverse outcomes, including recurrent hospitalization, but the reasons for this are unclear. We sought to evaluate whether gaps in prescribing maintenance inhalers were associated with recurrent hospitalization. Methods/Study Population: All asthma exacerbations, defined by ICD-10 codes, among adults requiring an emergency department (ED) visit or hospitalization at any of 5 hospitals in our health system were classified as BMA or non-BMA (i.e., planned) discharges using EHR data. We evaluated whether an inhaled corticosteroid and long-acting beta-agonist (ICS/LABA) inhaler was prescribed on discharge, and whether they had a recurrent exacerbation within 30 days. We used logistic regression models adjusted for age, sex, exacerbation history, medical center, encounter type (ED or admission), BiPAP use, insurance, prior ICS/LABA prescription to evaluate risk of 30-day re-exacerbation by ICS/LABA prescription, BMA discharge, and the interaction between those variables. Results/Anticipated Results: This cohort included 13,064 exacerbations, and 330 (2.5%) resulted in BMA discharge. Compared to non-BMA discharges, those discharging BMA were younger (40 vs 43 years) and less often female (48% vs 64%). Those discharging BMA were less likely to receive an ICS/LABA prescription (16% vs 23%, p=0.01) and more likely to experience 30-day re-exacerbation (12% vs 7%, p=0.001). In adjusted analyses, BMA discharge increased the risk of 30-day re-exacerbation (OR 1.79, 95% CI: 1.22-2.64) and ICS/LABA prescription was protective (OR 0.79, 95% CI: 0.65-0.96). There was a significant interaction (OR for interaction: 0.11, 95% CI 0.01-0.85), indicating a stronger protective association of ICS/LABA among those discharging BMA. Discussion/Significance of Impact: Prescribing an ICS/LABA at discharge protects against recurrent severe asthma exacerbations within 30 days. This association is strongest among those discharging BMA, highlighting this susceptible population as requiring further attention to address gaps in care.