Adjusted Mean Length Of Stay Research Articles

Variation in Length of Stay by Level of Neonatal Care Among Moderate and Late Preterm Infants.

Moderate and late preterm infants are a growing subgroup of neonates with increased care needs after birth, yet standard protocols are lacking. We aim to describe variation in length of stay (LOS) by gestational age (GA) across hospitals within the same level of neonatal care and between different levels of neonatal care. Retrospective cohort study of hospitalizations for moderate (32-33 weeks GA) and late (34-36 weeks GA) preterm infants in 2019 Kid's Inpatient Database. We compared adjusted LOS in this cohort and evaluated variation within hospitals of the same level and across different levels of neonatal care. This study includes 217 051 moderate (26.2%) and late (73.8%) preterm infants from level II (19.7%), III (66.3%), and IV (11.1%) hospitals. Patient-level (race and ethnicity, primary payor, delivery type, multiple gestation, birth weight) and hospital-level (birth region, level of neonatal care) factors were significantly associated with LOS. Adjusted mean LOS varied for hospitals within the same level of neonatal care with level II hospitals showing the greatest variability among 34- to 36- week GA infants when compared with level III and IV hospitals (P < .01). LOS also varied significantly between levels of neonatal care with the greatest variation (0.9 days) seen in 32-week GA between level III and level IV hospitals. For moderate and late preterm infants, the level of neonatal care was associated with variation in LOS after adjusting for clinical severity. Hospitals providing level II neonatal care showed the greatest variation and may provide an opportunity to standardize care.

Abstract 13455: Clinical Outcomes of Intravascular Ultrasound During Percutaneous Coronary Intervention- United States Nation-Wide Analysis 2014 Through 2019

Introduction: Intravascular Ultrasound (IVUS) is a catheter-based real-time imaging procedure that assists in both diagnosis and treatment during Percutaneous Coronary Intervention (PCI). Over the years, IVUS-guided PCI have become more popular. In this study, we aimed to analyze the trends of use of IVUS-guided PCI, adjusted in-hospital mortality, hospital length of stay (LOS) and inpatient cost over the years. Methods: Data were extracted from the National Inpatient Sample (NIS) 2014 through 2019 Database. The NIS was searched for PCI with and without IVUS in adult patients (age ≥ 18) using ICD 9 and 10 codes. Outcomes of interest were utilization rates of IVUS during PCI, trend of adjusted in-hospital mortality, adjusted mean LOS and adjusted mean cost. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders. STATA software was used for analysis. Results: Of 2,871,865 PCIs in 2014 through 2019, 201,075 (7.0%) were coupled with IVUS. The use of IVUS during PCI steadily increased from 6.2% in 2014 to 9.3% in 2019 (trend p&lt;0.001). The adjusted in-hospital mortality and inpatient LOS for PCI with IVUS showed statistically insignificant trend of higher mortality (1.3% in 2014 vs. 1.6% in 2019, trend p=0.053) and shorter LOS (3.2 days in 2014 vs. 3.0 days in 2019, trend p=0.148). The mean adjusted cost steadily increased over the years for patients undergoing PCI with IVUS (24236$ in 2014 vs. 28700$ in 2019, trend p=0.012). Conclusions: There is a steady rise in use of IVUS during PCI. There is a steady hike in hospital costs for PCI with IVUS hospitalizations however in-hospital mortality and LOS remain the same.

Abstract 13454: Utilization Rate and Outcome Trends for Watchman Procedure - Nationwide Analysis

Introduction: Left atrial appendage closure is increasingly offered to patients with atrial fibrillation who are poor candidates for long-term anticoagulation. We set out to determine the utilization rates and adjusted outcome trends for the WATCHMAN procedure. Methods: Data were extracted from the National Inpatient Sample (NIS) 2015 through 2019 Database. The NIS was searched for atrial appendage closure in adult patients (age ≥ 18) using ICD 9 and 10 codes. Outcomes of interest were utilization rates of WATCHMAN procedure through time, trends of adjusted mean length of stay (LOS), and adjusted mean cost. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders. STATA software was used for analysis. Results: There were 63,190 WATCHMAN procedures performed from 2015 through 2019. The mean patient age was 76 years, and 58% were males. The utilization rates of the WATCHMAN procedure steadily increased from 1800 in 2015 to 26,915 in 2019 (the rise was steeper for females than males and for Caucasians than African Americans). The adjusted mean LOS decreased from 3.4 days to 1.4 days, trend p&lt;0.001. No statistically significant linear trend was observed in terms of adjusted mean hospital cost (32784$ in 2014 vs. 27385$ in 2019, trend p=0.071). Conclusions: There has been a steady rise in the use of WATCHMAN procedure in the United States, more so in females than males and in Caucasians than African Americans. Over the years, there has been a decrease in LOS for WATCHMAN hospitalizations, however, the hospital cost remained unchanged.

Impact of cannabis use in patients with implantable cardiac defibrillators admitted with acute heart failure: a national perspective

Abstract Background Cannabis is the most popular recreational drug in the United States but knowledge about its health implications remain limited. Cannabis use has been linked to acute myocardial infarction and congestive heart failure. The effect of cannabis use in acute decompensated heart failure in patients with Implantable Cardiac Defibrillators (ICDs) is not known. Objective In this study, we sought to explore the impact of cannabis use in patients with Implantable Cardiac Defibrillators (ICDs) admitted with acute decompensated heart failure. Methods We queried the 2019 National Inpatient Sample (NIS) database for all patients aged ≥18 with ICD devices admitted with acute heart failure. Patients were stratified into two groups based on Cannabis use. We excluded patients with opioid, amphetamine, psychostimulants, cocaine, sedative, and hallucinogen abuse disorders to eliminate the effect of polysubstance use. Results Of the 174,295 hospitalization events for acute decompensated heart failure with ICDs, 1824 were noted to have diagnosis of cannabis use (CU). Patients with CU were younger (mean age 52.4y vs 68.5y) and mostly male (81.1% vs 18.9%). CU group had lower prevalence rates for anemia, atrial fibrillation, coronary artery disease, diabetes, cirrhosis, chronic kidney disease and hypothyroidism. They had higher rates of alcoholism, tobacco use and depression. The primary outcome studied was inpatient mortality. Secondary outcomes include cardiac arrest, myocardial infarction, cardiogenic shock, ventricular tachycardia, ventricular fibrillation, stroke, respiratory failure, pleural effusion, acute kidney injury, length of stay (LoS) and hospital charges. Patients in CU group were noted to have decreased length of stay (reduction in adjusted mean LoS: 2.14 days, P=0.000), mortality (adjusted OR: 0.14, P=0.006) and respiratory failure (adjusted OR: 0.53, P=0.009). Conclusion Among patients with implantable cardiac defibrillator admitted for acute decompensated heart failure, cannabis users were younger and mostly male. These patients were noted to have decreased length of stay, inpatient mortality, and respiratory failure. Funding Acknowledgement Type of funding sources: None.

Examining the patient profile and variance of management and in-hospital outcomes for Australian adult burns patients.

Burn injuries are a common subtype of trauma. Variation in models of care impacts clinical measures of interest, but a nation-wide examination of these measures has not been undertaken. Using data from the Burns Registry of Australia and New Zealand (BRANZ), we explored variation between Australian adult burn services with respect to treatment and clinical measures of interest. Data for admissions July 2016 to June 2020 were extracted. Clinical measures of interest included intensive care admission, skin grafting, in-hospital death, unplanned readmissions, and length of stay (LOS). Estimated probabilities, means, and corresponding 95% confidence intervals (CI) were calculated for each service. The BRANZ recorded 8365 admissions during the study period. Variation between specialist burn services in admissions, demographics, management, and clinical measures of interest were observed. This variation remained after accounting for covariates. Specifically, the adjusted proportion (95% CI) of in-hospital mortality ranged from 0.15% (0.10-0.21%) to 1.22% (0.9-1.5%). The adjusted mean LOS ranged from 3.8 (3.3-4.3) to 8.2 (6.7-9.7) days. A decade after its launch, BRANZ data displays variation between Australian specialist burn services. We suspect differences in models of care between services contributes to this variation. Ongoing research has begun to explore reasons underlying how this variation influences clinical measures of interest. Further engagement with services about models of care will enhance understanding of this variation and develop evidence-based guidelines for burn care in Australia.

Does Maternal Incarceration Impact Infants with Neonatal Abstinence Syndrome?

Opioid exposed infants born to incarcerated women represent a vulnerable and understudied subset of infants with neonatal abstinence syndrome (NAS). The impact of maternal incarceration on length of stay (LOS) for infants with NAS is unknown. We hypothesized that infants with NAS born to incarcerated women have longer hospitalizations compared to infants with NAS born to non-incarcerated women. This is a retrospective cohort study of infants with NAS born between 2011 and 2018 at the primary delivery site for Connecticut's only women's prison. Opioid exposed infants were assessed by Finnegan Scores for withdrawal and received morphine as a first line agent and phenobarbital as a second line agent. LOS was compared using Poisson regression. Of 206 infants identified, 166 were included in the analysis, with 28 born to incarcerated women and 138 to non-incarcerated women. Incarcerated women were more likely to report prenatal alcohol use, 14.3% vs 2.2% p = 0.016 and benzodiazepine use 21.4% vs 7.3% p = 0.032. Infants of incarcerated women were less likely to be fed breast milk at discharge, 3.6% vs 37% p < 0.001. Adjusted mean LOS was longer among infants born to incarcerated women, 18.5 vs 16.6days (p = 0.009). Infants with NAS born to incarcerated women in Connecticut had longer LOS, lower rates of being fed breast milk, and different prenatal substance exposures than infants with NAS born to non-incarcerated women. Supporting the maternal-infant dyad until infant discharge may mitigate the potential negative impact of maternal incarceration on the care of infants with NAS.

Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old.

Researchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24-36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children's hospitals. We conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions. We identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 (P < .001). There was substantial variation in adjusted mean LOS across children's hospitals, range 33.5-77.9 hours in 2016 and 30.4-100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (-23.9 to +26.7 hours; median change -1.8 hours, interquartile range: -5.4 to 0.3). There was no association between hospital-level LOS and readmission rates (P = .70). The LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children's hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.

Outcomes Following Implementation of a Hospital-Wide, Multicomponent Delirium Care Pathway.

Delirium is associated with poor clinical outcomes that could be improved with targeted interventions. To determine whether a multicomponent delirium care pathway implemented across seven specialty nonintensive care units is associated with reduced hospital length of stay (LOS). Secondary objectives were reductions in total direct cost, odds of 30-day hospital readmission, and rates of safety attendant and restraint use. This retrospective cohort study included 22,708 hospitalized patients (11,018 preintervention) aged ≥50 years encompassing seven nonintensive care units: neurosciences, medicine, cardiology, general and specialty surgery, hematology-oncology, and transplant. The multicomponent delirium care pathway included a nurse-administered delirium risk assessment at admission, nurse-administered delirium screening scale every shift, and a multicomponent delirium intervention. The primary study outcome was LOS for all units combined and the medicine unit separately. Secondary outcomes included total direct cost, odds of 30-day hospital readmission, and rates of safety attendant and restraint use. Adjusted mean LOS for all units combined decreased by 2% post intervention (proportional change, 0.98; 95% CI, 0.96-0.99; P = .0087). Medicine unit adjusted LOS decreased by 9% (proportional change, 0.91; 95% CI, 0.83-0.99; P = .028). For all units combined, adjusted odds of 30-day readmission decreased by 14% (odds ratio [OR], 0.86; 95% CI, 0.80-0.93; P = .0002). Medicine unit adjusted cost decreased by 7% (proportional change, 0.93; 95% CI, 0.89-0.96; P = .0002). This multicomponent hospital-wide delirium care pathway intervention is associated with reduced hospital LOS, especially for patients on the medicine unit. Odds of 30-day readmission decreased throughout the entire cohort.

Post-stroke lateropulsion and rehabilitation outcomes: a retrospective analysis

Purpose A person with post-stroke lateropulsion actively pushes themselves toward their hemiplegic side, or resists moving onto their non-hemiplegic side. This study aimed to determine the association of lateropulsion severity with: • Change in function (Functional Independence Measure – FIM) and lateropulsion severity (Four-Point Pusher Score – 4PPS) during inpatient rehabilitation; • Inpatient rehabilitation length of stay (LOS); • Discharge destination from inpatient rehabilitation. Methods Retrospective data for 1,087 participants (aged ≥65 years) admitted to a stroke rehabilitation unit (2005–2018) were analysed using multivariable regression models. Results Complete resolution of lateropulsion was seen in 69.4% of those with mild lateropulsion on admission (n = 160), 49.3% of those with moderate lateropulsion (n = 142), and 18.8% of those with severe lateropulsion (n = 181). Average FIM change was lower in those with severe lateropulsion on admission than those with no lateropulsion (p < 0.001). Higher admission 4PPS was associated with reduced FIM efficiency (p < 0.001), longer LOS (p < 0.001), (adjusted mean LOS: 35.6 days for those with severe lateropulsion versus 27.0 days for those without), and reduced likelihood of discharge home (p < 0.001). Conclusion Post-stroke lateropulsion is associated with reduced functional improvement and likelihood of discharge home. However, given a longer rehabilitation duration, most stroke survivors with moderate to severe lateropulsion can achieve important functional improvement. Implications for Rehabilitation While people with post-stroke lateropulsion can be difficult to treat and require more resources than those without lateropulsion, the majority of those affected, even in severe cases, can make meaningful recovery with appropriate rehabilitation. Although those with moderate to severe post-stroke lateropulsion may have poorer outcomes (longer LOS and reduced likelihood of discharge home) it is still important to advocate for access to rehabilitation for this patient group to give them the opportunity for optimal functional recovery.

Renal Involvement in Granulomatosis With Polyangiitis Increases Economic Health Care Burden: Insights From the National Inpatient Sample Database.

BackgroundThis study aims to compare outcomes of hospitalizations of granulomatosis with polyangiitis (GPA) with and without renal involvement. The primary outcome was inpatient mortality, whereas secondary outcomes were hospital length of stay (LOS) and total hospital charge.MethodsData were abstracted from the National Inpatient Sample (NIS) 2016 and 2017 databases. The NIS was searched for GPA hospitalizations with and without renal involvement as the principal or secondary diagnosis using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10) codes. GPA hospitalizations for adult patients from the above groups were identified. Multivariate logistic and linear regression analyses were used to adjust for possible confounders for the primary and secondary outcomes, respectively.ResultsThere were more than 71 million discharges included in the combined 2016 and 2017 NIS database, of which 23,670 were for adult patients who had either a principal or secondary ICD-10 code for GPA, and 8,265 (34.92%) of these GPA hospitalizations had renal involvement.Hospitalizations for GPA with renal involvement had similar inpatient mortality (3.8% vs. 3.7%; adjusted OR: 1.14; 95% CI: 0.84-1.56; p=0.406) compared to those without renal involvement. GPA with renal involvement hospitalizations had an increase in adjusted mean LOS of 1.36 days (95% CI: 0.82-1.91; p=0.0001) compared to those without renal involvement. GPA with renal involvement hospitalizations had an increase in adjusted total hospital charges of $18,723 (95% CI: 9,595-27,852; p=0.0001) compared to those without renal involvement.ConclusionsGPA with renal involvement hospitalizations had similar inpatient mortality compared to those without renal involvement. However, LOS and total hospital charges were greater in those with renal involvement.

Psoriatic Arthritis Hospitalization Is Associated with Increased Health Care Charges: A Report from the National Inpatient Sample.

Background: This study aims to compare the outcomes of psoriasis hospitalizations with and without joint involvement. The primary outcome was inpatient mortality, while secondary outcomes were hospital length of stay (LOS) and total hospital charges.Methods: Data were abstracted from the National Inpatient Sample (NIS) 2016 and 2017 databases. The NIS was searched for psoriasis hospitalizations with and without joint involvement as principal or secondary diagnosis using the International Classification of Diseases, tenth revision (ICD-10) codes. Psoriasis hospitalizations for adult patients (aged ≥18 years) from the above groups were identified. Multivariate logistic and linear regression analysis was used to adjust for confounders for the primary and secondary outcomes, respectively.Results: There were over 71 million discharges included in the combined 2016 and 2017 NIS database. A total of 323,405 hospitalizations were for adult patients with either a principal or secondary ICD-10 code for psoriasis. Of these hospitalizations, 77,980 (24.11%) had joint involvement. Psoriasis hospitalizations with joint involvement had similar inpatient mortality (1.42% vs. 1.78%, adjusted odds ratio (AOR): 0.89, 95% CI: 0.76-1.05, p=0.159) compared with those without joint involvement. Psoriasis with joint involvement hospitalizations had a decrease in adjusted mean LOS of 0.15 days (95% CI: 0.26-0.04, p=0.007) compared with the group without joint involvement. Psoriasis with joint involvement hospitalizations had an increase in adjusted mean total hospital charges of $3,655 (95% CI: 2,146-5,164; p<0.0001) compared with the group without joint involvement.Conclusions: Hospitalizations for psoriasis with and without joint involvement have similar inpatient mortality. However, joint involvement increases total hospital charges, which increases the burden to the health care system.

Effectiveness of Alberta Family Integrated Care on infant length of stay in level II neonatal intensive care units: a cluster randomized controlled trial

BackgroundParents of infants in neonatal intensive care units (NICUs) are often unintentionally marginalized in pursuit of optimal clinical care. Family Integrated Care (FICare) was developed to support families as part of their infants’ care team in level III NICUs. We adapted the model for level II NICUs in Alberta, Canada, and evaluated whether the new Alberta FICare™ model decreased hospital length of stay (LOS) in preterm infants without concomitant increases in readmissions and emergency department visits.MethodsIn this pragmatic cluster randomized controlled trial conducted between December 15, 2015 and July 28, 2018, 10 level II NICUs were randomized to provide Alberta FICare™ (n = 5) or standard care (n = 5). Alberta FICare™ is a psychoeducational intervention with 3 components: Relational Communication, Parent Education, and Parent Support. We enrolled mothers and their singleton or twin infants born between 32 0/7 and 34 6/7 weeks gestation. The primary outcome was infant hospital LOS. We used a linear regression model to conduct weighted site-level analysis comparing adjusted mean LOS between groups, accounting for site geographic area (urban/regional) and infant risk factors. Secondary outcomes included proportions of infants with readmissions and emergency department visits to 2 months corrected age, type of feeding at discharge, and maternal psychosocial distress and parenting self-efficacy at discharge.ResultsWe enrolled 654 mothers and 765 infants (543 singletons/111 twin cases). Intention to treat analysis included 353 infants/308 mothers in the Alberta FICare™ group and 365 infants/306 mothers in the standard care group. The unadjusted difference between groups in infant hospital LOS (1.96 days) was not statistically significant. Accounting for site geographic area and infant risk factors, infant hospital LOS was 2.55 days shorter (95% CI, − 4.44 to − 0.66) in the Alberta FICare™ group than standard care group, P = .02. Secondary outcomes were not significantly different between groups.ConclusionsAlberta FICare™ is effective in reducing preterm infant LOS in level II NICUs, without concomitant increases in readmissions or emergency department visits. A small number of sites in a single jurisdiction and select group infants limit generalizability of findings.Trial registrationClinicalTrials.gov Identifier NCT02879799, retrospectively registered August 26, 2016.

Rheumatoid Arthritis Does Not Negatively Impact Outcomes of Patients Admitted for Atrial Fibrillation.

ObjectivesThis study aimed to compare the outcomes of patients primarily admitted for atrial fibrillation (AF) with and without a secondary diagnosis of rheumatoid arthritis (RA). The primary outcome of interest was inpatient mortality. Hospital length of stay (LOS), total hospital charges, and odds of undergoing ablation and pharmacologic cardioversion were the secondary outcomes of interest.MethodsData were abstracted from the National Inpatient Sample (NIS) 2016 and 2017 databases. The NIS is the largest hospitalization database in the United States (US). The NIS was searched for hospitalizations for adult patients with AF as principal diagnosis with and without RA as secondary diagnosis using the International Classification of Diseases, 10th Revision (ICD-10) codes. Multivariate logistic and linear regression analysis was used accordingly to adjust for confounders.ResultsThere were over 71 million discharges in the combined 2016 and 2017 NIS database. Out of 821,630 AF hospitalizations, 17,020 (2.1%) had RA. Hospitalizations for AF with RA had 0.18 days' decrease in adjusted mean LOS (p=0.014), and lower total hospital charges ($38,432 vs $39,175, p=0.018) compared to those without RA. AF hospitalizations with RA had similar inpatient mortality [1.1% vs 0.91%, adjusted odds ratio (AOR): 0.90, 95% CI: 0.63-1.27, p=0.540] and odds of undergoing ablation (3.5% vs 4.2%, AOR: 1.1, 95% CI: 0.87-1.30, p=0.549) and pharmacologic cardioversion (0.38% vs 0.38%, AOR: 1.00, 95% CI: 0.53-1.89, p=0.988) compared to those without RA.ConclusionsPatients admitted for AF with coexisting RA were found to have lesser adjusted mean LOS and lower total hospital charges compared to those without RA. However, inpatient mortality and the odds of undergoing ablation and pharmacologic cardioversion were similar between both groups.

193-LB: Diabetes Mellitus Does Not Impact Negatively on Outcomes of Hospitalizations Primarily for Systemic Lupus Erythematosus (SLE): An Analysis of the National Inpatient Sample Database

Background: Diabetes mellitus (DM) is a multisystemic disorder, known to be associated with worse outcomes of multiple conditions. Objectives: This study aims to determine if diabetes has an impact on outcomes of hospitalizations primarily for SLE. Methods: Data were extracted from the Nationwide Inpatient Sample (NIS) 2016 and 2017 database. The NIS was searched for SLE as the principal diagnosis for hospitalizations in 2016 and 2017, with and without DM as a secondary diagnosis, using ICD-10 codes. Adult Patients from the above groups were included. The primary outcome was inpatient mortality, while secondary outcomes were length of stay (LOS) and Total hospital charge. Multivariate logistic and linear regression analysis were used to adjust for possible confounders for the primary and secondary outcomes respectively. Results: 20630 hospitalizations were for adult patients, who had principal diagnosis of SLE. 18560 (90.0%) of these hospitalizations had no secondary diagnosis of DM and 2070 (10.0%) had a secondary diagnosis of DM. A total of 255 inpatient mortality (1.23%) occurred in SLE hospitalizations, 35 (1.19%) of which occurred in patients with DM. The adjusted odds ratio (AOR) of inpatient mortality for SLE with DM compared to without DM was 0.554 (95% CI: 0.233 - 1.315, P=0.180). Hospitalizations with SLE and DM had a decreased adjusted mean LOS of 2.1 days (95% CI -3.0 - {-1.1}, P=0.000) compared to without DM. The adjusted mean total hospital charge for SLE and DM hospitalizations was also decreased by $24875 compared to without DM (95% CI -36154 - {-13596}, P=0.000). Conclusions: There was no statistically significant difference in inpatient mortality of hospitalizations for SLE with DM compared to SLE without DM. Interestingly, SLE with DM hospitalizations has a shorter LOS and lower total hospital charge compared to without DM. Disclosure E. Edigin: None. H. Shaka: None. J. Xu: None. S.T. Yap: None. M. Padilla Sorto: None.

Determinants of Length of Stay After Vaginal Deliveries in the Friuli Venezia Giulia Region (North-Eastern Italy), 2005\u20132015

Although length of stay (LoS) after childbirth has been diminishing in several high-income countries in recent decades, the evidence on the impact of early discharge (ED) on healthy mothers and term newborns after vaginal deliveries (VD) is still inconclusive and little is known on the characteristics of those discharged early. We conducted a population-based study in Friuli Venezia Giulia (FVG) during 2005–2015, to investigate the mean LoS and the percentage of LoS longer than our proposed ED benchmarks following VD: 2 days after spontaneous vaginal deliveries (SVD) and 3 days post instrumental vaginal deliveries (IVD). We employed a multivariable logistic as well as a linear regression model, adjusting for a considerable number of factors pertaining to health-care setting and timeframe, maternal health factors, newborn clinical factors, obstetric history factors, socio-demographic background and present obstetric conditions. Results were expressed as odds ratios (OR) and regression coefficients (RC) with 95% confidence interval (95%CI). The adjusted mean LoS was calculated by level of pregnancy risk (high vs. low). Due to a very high number of multiple tests performed we employed the procedure proposed by Benjamini-Hochberg (BH) as a further selection criterion to calculate the BH p-value for the respective estimates. During 2005–2015, the average LoS in FVG was 2.9 and 3.3 days after SVD and IVD respectively, and the pooled regional proportion of LoS > ED was 64.4% for SVD and 32.0% for IVD. The variation of LoS across calendar years was marginal for both vaginal delivery modes (VDM). The adjusted mean LoS was higher in IVD than SVD, and although a decline of LoS > ED and mean LoS over time was observed for both VDM, there was little variation of the adjusted mean LoS by nationality of the woman and by level of pregnancy risk (high vs. low). By contrast, the adjusted figures for hospitals with shortest (centres A and G) and longest (centre B) mean LoS were 2.3 and 3.4 days respectively, among “low risk” pregnancies. The corresponding figures for “high risk” pregnancies were 2.5 days for centre A/G and 3.6 days for centre B. Therefore, the shift from “low” to “high” risk pregnancies in all three latter centres (A, B and G) increased the mean adjusted LoS just by 0.2 days. By contrast, the discrepancy between maternity centres with highest and lowest adjusted mean LoS post SVD (hospital B vs. A/G) was 1.1 days both among “low risk” (1.1 = 3.4–2.3 days) and “high risk” (1.1 = 3.6–2.5) pregnanices. Similar patterns were obseved also for IVD. Our adjusted regression models confirmed that maternity centres were the main explanatory factor for LoS after childbirth in both VDM. Therefore, health and clinical factors were less influential than practice patterns in determining LoS after VD. Hospitalization and discharge policies following childbirth in FVG should follow standardized guidelines, to be enforced at hospital level. Any prolonged LoS post VD (LoS > ED) should be reviewed and audited if need be. Primary care services within the catchment areas of the maternity centres of FVG should be improved to implement the follow up of puerperae undergoing ED after VD.

Endoscopy Is Relatively Safe in Patients with Acute Ischemic Stroke and Gastrointestinal Hemorrhage.

Gastrointestinal hemorrhage (GIH) is reported to occur in 1-8% of patients admitted with acute ischemic stroke (AIS). AIS is considered to be a relative contraindication to GIE. Evaluate the outcomes of gastrointestinal endoscopy (GIE) in patients hospitalized with AIS and GIH. Patients hospitalized with AIS and GIH were included from the National Inpatient Sample 2005-2014. Primary outcome measure was in-hospital mortality in patients with AIS and GIH who underwent gastrointestinal endoscopy. Secondary outcomes were (1) resource utilization as measured by length of stay (LOS) and total hospitalization costs and (2) to identify independent predictors of undergoing GIE in patients with AIS and GIH. Confounders were adjusted for by using multivariable regression analysis. A total of 75,756 hospitalizations were included in the analysis. Using a multivariate analysis, the in-hospital mortality was significantly lower in patients who underwent GIE as compared to those who did not [aOR: 0.4, P < 0.001]. Patients who underwent GIE also had significantly shorter adjusted mean LOS [adjusted mean difference in LOS: 0.587days, P < 0.001]. Patients with AIS and GIH who did not undergo GIE had significantly higher adjusted total hospitalization costs. [Mean adjusted difference in total hospitalization costs was $5801 (P < 0.001).] Independent predictors of undergoing GIE in this population were male gender, age > 65years, Asian or Pacific race, hypovolemic shock, need for blood transfusion and admission to urban non-teaching hospital. Gastrointestinal endoscopy can be safely performed in a substantial number of patients with AIS and GIH.

Burden of illness and costs among paediatric haemophilia patients with and without central venous access devices treated in US hospitals.

Central venous access devices (CVADs) facilitate repeated or urgent treatments for paediatric haemophilia patients, but are associated with complications. This study examined the burden of illness, healthcare utilization and costs for CVADs in a real-world hospital setting. This study included haemophilia patients ages ≤18years with discharges during 2006-2014 in the US Premier Healthcare Database. Haemophilia was identified using ICD-9 diagnosis codes and CVAD exposure using billing information. After matching haemophilia patients with and without CVADs on demographic and clinical characteristics, we compared infection, thrombosis, length of stay (LOS), inflation-adjusted hospital cost (2014 $USD) and readmission outcomes using generalized estimating equation models adjusted for hospital teaching status. Among 4793 paediatric haemophilia patients treated at one of 548 hospitals, a total of 197 patients were identified with CVAD exposure. The matched sample included 310 haemophilia patients (155 CVAD and 155 non-CVAD). CVAD cases had greater frequencies of all-cause infections (29% vs 17%, P=.01) and thrombosis (6% vs 1%, P=.06), longer adjusted mean LOS (9.5 vs 4.7days, P=.002), higher adjusted mean inpatient total hospitalization costs ($47200 vs $25389, P=.02) as well as more inpatient and outpatient visits at 30-, 60- and 90-days (P<.05 for all differences) compared with non-CVAD patients. Paediatric haemophilia patients with CVADs experienced greater infection rates, healthcare utilization and higher hospitalization costs compared with non-CVAD patients. The results of this study may inform further research efforts to understand the costs and benefits of novel treatment alternatives for young haemophilia patients requiring CVADs.

Economic Impact of Laparoscopic Conversion to Open in Left Colon Resections

Background and Objectives:Studies have shown economic and clinical advantages of laparoscopic left-colon resections. Laparoscopic conversion to open is an important surgical outcome. We estimated conversion incidence, identified risk factors, and measured the clinical and economic impact.Methods:In this retrospective study, we used the Premier Perspective database to analyze left-sided colectomies from 2009 to 2014. Operating room time (ORT), length of stay (LOS), total hospital cost (2014 U.S. dollars); along with incidence of in-hospital clinical outcomes (anastomotic leak surrogate [Leak], transfusion, and mortality) were evaluated. Multivariable models accounting for hospital clustering were used to identify conversion risk factors and analyze the effect of conversion on economic and clinical outcomes.Results:A total of 41,417 patients: 8,468 left hemicolectomy and 32,949 sigmoidectomy were identified. Lap-Conversion incidence was 13.3% (95% CI, 12.9–13.7). Adjusted mean LOS (±SE) days was significantly lower for the Lap-Successful group (4.9 compared with Lap-Conversion 6.8 and Open-Planned 7.0), but Lap-Conversion and Open-Planned had similar LOS. Adjusted mean cost was higher for Lap-Conversion $20,165 compared to Open-Planned $18,797; but this difference was smaller than the cost savings for Lap-Successful $16,206 ± $219. Open-Planned had lower odds of Leak compared to Lap-Conversion. Open-Planned and Lap-Conversion had similar odds of transfusion and mortality. Conversion risk factors included inflammatory bowel disease and left-hemicolectomy. Colorectal specialists were associated with 38% decreased odds of conversion.Conclusions:Successful laparoscopic surgery was the most cost effective, with decreased LOS and odds of blood transfusion, leak surrogate, and mortality. Conversion was the most expensive and had increased odds of leak surrogate, but similar LOS compared to Open-Planned. The beneficial effect size of successful laparoscopic surgery was larger than the negative effect of conversion compared to Open-Planned.

Pulmonary Embolism Inpatients Treated With Rivaroxaban Had Shorter Hospital Stays and Lower Costs Compared With Warfarin

PurposeUsing real-world data, this study compares inpatient length of stay (LOS) and costs for patients with a primary diagnosis of pulmonary embolism (PE) initiating treatment with oral anticoagulation with rivaroxaban versus warfarin. MethodsHospitalizations from MarketScan’s Hospital Drug Database were selected from November 1, 2012, through December 31, 2013, for adults with a primary diagnosis of PE initiating treatment with rivaroxaban or warfarin. Warfarin patients were matched 1:1 to rivaroxaban patients using exact and propensity score matching. Hospital LOS, treatment patterns, and hospitalization costs were evaluated. FindingsMatched cohorts included 751 rivaroxaban-treated patients and 751 warfarin-treated patients. Adjusted mean LOS was 3.77 days for rivaroxaban patients (95% CI, 3.66–3.87 days) and 5.48 days for warfarin patients (95% CI, 5.33–5.63 days; P < .001). Mean (SD) LOS was shorter for patients taking rivaroxaban whether admission was for provoked PE (rivaroxaban: 5.2 [5.1] days; warfarin: 7.0 [6.5] days; P < .001) or unprovoked PE (rivaroxaban: 3.4 [2.3] days; warfarin: 5.1 [2.7] days; P < .001). Mean (SD) days from first dose to discharge were 2.5 (1.7) (rivaroxaban) and 4.0 (2.9) (warfarin) when initiated with parenteral anticoagulants (P < .001) and 2.7 (1.7) (rivaroxaban) and 4.0 (2.2) (warfarin) without parenteral anticoagulants (P < .001). The rivaroxaban cohort incurred significantly lower unadjusted mean (SD) hospitalization costs (rivaroxaban: $8473 [$9105]; warfarin: $10,291 [$9185]; P < .001), confirmed by covariate adjustment with generalized linear modeling estimating predicted mean hospitalization costs of $8266 for rivaroxaban patients (95% CI, $7851–$8681) and $10,511 for warfarin patients (95% CI, $10,031–$10,992; P < .001). Implicationspatients with PE treated with rivaroxaban incurred significantly lower hospitalization costs by $2245 per admission compared with patients treated with warfarin, which was attributable to cost offsets from 1.71 fewer days of stay in the hospital.

Clostridium difficile infection in patients hospitalized with type 2 diabetes mellitus and its impact on morbidity, mortality, and the costs of inpatient care

AimsType 2 diabetes mellitus (T2DM) is often complicated by infections leading to hospitalization, increased morbidity, and mortality. Not much is known about the impact of Clostridium difficile infection (CDI) on health outcomes in hospitalized patients with T2DM. We estimated the prevalence and temporal trends of CDI; evaluated the associations between CDI and in-hospital mortality, length of stay (LOS), and the costs of inpatient care; and compared the impact of CDI with that of other infections commonly seen in patients with T2DM. MethodsWe conducted a cross-sectional analysis using data from the Nationwide Inpatient Sample among patients ⩾18years with T2DM and generalized linear regression was used to analyze associations and jointpoint regression for trends. ResultsThe prevalence of CDI was 6.8 per 1000 hospital discharges. Patients with T2DM and CDI had increased odds of in-hospital mortality (OR, 3.63; 95% CI 3.16, 4.17). The adjusted mean LOS was higher in patients with CDI than without CDI (11.9 vs. 4.7days). That translated to average hospital costs of $23,000 and $9100 for patients with and without CDI, respectively. The adjusted risk of mortality in patients who had CDI alone (OR 3.75; 95% CI 3.18, 4.41) was similar to patients who had CDI in addition to other common infections (OR 3.25; 95% CI 2.58, 4.10). ConclusionCDI is independently associated with poorer health outcomes in patients with T2DM. We recommend close surveillance for CDI in hospitalized patients and further studies to determine the cost effectiveness of screening for CDI among patients with T2DM.