S674 The Disparity in Hospitalization Outcomes for Patients With Variceal Hemorrhage Based on the Patients’ Living Area Household Income: A Study of the National Inpatient Sample

Abstract

Introduction: Variceal hemorrhage (VH) is a dreaded condition that requires urgent hospitalization. Multiple studies have shown that socioeconomic disparities are linked to poor healthcare outcomes. In this study, we aim to characterize the differences in the hospitalization outcomes of VH based on the household income area. Methods: Patients with a 1ry discharge diagnosis of VH were identified from the national inpatient sample (NIS) 2016-2018 data and classified based on household income for patients’ living areas as: low [LIA] (≤ 50% ) or high [HIA] ( >50%). The living area household income was provided by Claritas as a quartile classification per ZIP code and incorporated into the NIS data. Inverse probability weighting based on propensity score was used to adjust for differences between the two groups. Our outcomes include time to first esophagogastroduodenoscopy (EGD) (early: ≤ 24 hours vs late: > 24 hours), length of hospital stay (LOS), hospital charges, mortality, and discharge disposition. Results: Out of 62,775 included patients, 37,420 were identified as LIA group. These patients were more likely to be Black or Hispanic, covered by Medicare or Medicaid, admitted to larger bed-size hospitals, use tobacco, had lower Elixhauser’s comorbidity score, and diagnoses of shock compared to the HIA group (Table). In the outcome analyses, the LIA group had lower odds ratio (OR) of having early EGD (0.86, 95% CI 0.78 – 0.95, P 0.002) and higher OR of death (1.3, 95% CI 1.028 – 1.644, P 0.03). There were no differences in LOS (MD 0.12, 95% CI -0.09 – 0.34, P 0.26), hospital charges (MD $1699.61, 95% CI -1707.76 – 5106.98, P 0.33), discharge to nursing facilities (OR 1.01, 95% CI 0.82 – 1.25, P 0.9), discharge with visiting nurse (OR 1.08, 95% CI 0.9 – 1.29, P 0.42), and discharge to other hospitals (OR 0.81, 95% CI 0.619 – 1.053, P 0.11). In an interaction term analyses, the differences in the EGD timing between LIA and HIA groups did not explain the differences in death or other hospitalization outcomes (Figure) Conclusion: This notional study showed that patients who lived in LIA and were admitted with VH had less likelihood of receiving EGD within 24 hours and a higher likelihood of death despite having fewer comorbidities compared to patients who lived in HIA. However, the differences in EGD timing did not explain the differences in death. More studies are needed to confirm these findings and to help understand and minimize the disparity in the healthcare system in the United States.Figure 1.: Hospitalization outcomes for patients with VH based on the interaction term analyses of household income and EGD timing. Abbreviations: EGD = Esophagogastroduodenoscopy, LOS= Length of hospital stay, OSH= outside hospital, VNA= home visiting nurse. Table 1. - Baseline characteristics Characteristics LIA HIA P-value Total number (Weighted) 37,420 25,355 Age (mean(SD)) 56.10 (11.97) 57.02 (12.47) <0.001 Female (%) 12,060 (32.2) 8,200 (32.4) 0.9 Race (%) <0.001 White 21,125 (57.8) 16,800 (68.2) Black 2,975 (8.1) 1,015 (4.1) Hispanic 9,730 (26.6) 4,725 (19.2) Others 2,715 (7.4) 2,105 (8.5) Patient Location: NCHS Urban-Rural Code (%) <0.001 "Central" counties of ≥1 million population 11,925 (31.9) 8,900 (35.1) "Fringe" counties of ≥1 million population 4,380 (11.7) 8,760 (34.5) Counties of 250,000-999,999 population 9,840 (26.3) 5,060 (20.0) Counties of 50,000-249,999 population 4,810 (12.9) 1,765 (7.0) Not metropolitan or micropolitan counties 6,460 (17.3) 870 (3.4) Expected primary payer (%) <0.001 Medicare 12,075 (32.4) 7,995 (31.6) Medicaid 11,065 (29.7) 6,035 (23.8) Private insurance 8,150 (21.8) 8,445 (33.3) Self-pay/ Others/No charge 6,020 (16.1) 2,855 (11.3) Shock (%) 4,295 (11.5) 3,290 (13) 0.01 Acute kidney injury (%) 6,870 (18.4) 4,775 (18.8) 0.51 Acute respiratory failure (%) 4,180 (11.2) 2,690 (10.6) 0.33 Blood transfusion (%)* 0.35 (0.51) 0.38 (0.53) 0.001 FFP or clotting factors transfusion (%)* 0.13 (0.38) 0.14 (0.40) 0.03 Advanced vascular access (%)* 2,550 (6.8) 1,775 (7) 0.69 Intubation and mechanical ventilation (%)* 4,125 (11) 2,920 (11.5) 0.4 Weighted Elixhauser’s score (mean(SD)) 14.18 (11.17) 15.30 (11.15) <0.001 Alcohol use disorder 22,835 (61) 15,205 (60) 0.26 Tobacco use 10,585 (28.3) 6,215 (24.5) <0.001 Long-term (current) anticoagulant use (%) 790 (2.1) 475 (1.9) 0.35 Long-term (current) aspirin use (%) 2,140 (5.7) 1,395 (5.5) 0.6 Long-term (current) NSAID and other antiplatelets/antithrombotic use (%) 870 (2.3) 515 (2) 0.27 Bed size of the hospital <0.001 Small 5,835 (15.6) 5,305 (20.9) Medium 11,395 (30.5) 8,285 (32.7) Large 20,190 (54) 11,765 (46.4) Abbreviations: EGD = Esophagogastroduodenoscopy, FFP = Fresh frozen plasma, HIA = High income area, LIA = Low income area, NSAID = Nonsteroidal anti-inflammatory drugs, NCHS = National Center for Health Statistics, SD = Standard deviation.*Procedures were done prior on the same day of EGD.