All-cause Admissions Research Articles

Effect of influenza vaccination in solid organ transplant recipients: A nationwide population-based cohort study

Vaccination can prevent influenza in solid organ transplant (SOT) recipients. Using a modified season-specific approach over nine consecutive influenza seasons, we investigated influenza vaccination coverage and effectiveness in a population-based nationwide cohort study that included all SOT recipients aged ≥18years who were living in Denmark from December 1, 2007 to April 1, 2016. The primary outcome was the season-specific risk of all-cause pneumonia admission. Secondary outcomes were season-specific influenza-related admission, intensive care unit (ICU) admission, and all-cause mortality. Crude and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) were estimated using Cox proportional hazards regression models. In total, 11381 person-years of follow-up data were collected from 5745 SOT recipients, 48% of whom were vaccinated. Influenza vaccination was associated with a reduced risk of all-cause pneumonia admission (aHR, 0.83; 95% CI, 0.69-0.99; p=.035) and all-cause mortality (aHR, 0.60; 95% CI, 0.47-0.76; p=.001), but not influenza-related admission (aHR, 0.75; 95% CI, 0.46-1.22; p=.24) or ICU admission (aHR, 0.84; 95% CI, 0.67-1.06; p=.14) during the same season. Despite these benefits, uptake of influenza vaccination among SOT recipients was low. Therefore, annual influenza vaccination needs to be prioritized.

Impact of Breast Cancer Pathways on ER utilization and hospitalization.

423 Background:Optum’s Cancer Guidance Program promotes value-based care by ensuring that treatments follow evidence-based guidelines and encouraging the use of cancer therapy pathways. Criteria for selection of treatments for pathways include efficacy, toxicity and cost so Pathways could be expected to decrease emergency room utilization and hospitalizations that result from adverse events of therapy. We conducted this study to evaluate the impact of Pathways adherence (on vs. off Pathways) on hospital inpatient and emergency department utilization among commercially insured members with breast cancer. Methods: This cross-sectional matched case-control study used medical claims and prior authorization data to evaluate 12 months of program experience (11/1/2019 – 10/31/2020). Individuals were included if they were 19+ years old, enrolled in the health plan, had actively treated breast cancer (breast cancer diagnosis and 1+ cancer related treatment procedure), and had a cancer drug therapy prior authorization during the study period. On Pathway cases were matched to off Pathway controls with propensity score and outcomes were measured using generalized linear models. The propensity score was estimated using demographic characteristics, cost/utilization preceding the prior authorization request, and clinical indicators (HER2 status, advanced disease, adjuvant vs neoadjuvant therapy, multiple lines of therapy, ECOG /Karnofsky, regimen emetic risk). Outcomes were measured across the member’s treatment episode from first month of active cancer treatment to 3 months after last month of active cancer treatment. Results: Compared to those who were off Pathway (n = 1,001), patients treated with a Pathways regimen (n = 1,001) had 18% lower (p-value = 0.03) all-cause inpatient admissions, 14% lower (p-value = 0.10) cancer-related inpatient admissions, 18% lower (p-value = 0.11) all-cause emergency department visits, no difference in (p-value = 1.00) cancer-related inpatient bed days, 8% lower (p-value = 0.31) all-cause emergency department visits, and 1% lower (p-value = 0.92) cancer-related emergency department visits. Conclusions: Treatment with a Pathway regimen was associated with fewer all-cause and cancer-related visits to inpatient hospitalizations and fewer all-cause inpatient bed days.

Telemedicine use and outcomes after transient ischemic attack and minor stroke during the COVID-19 pandemic: a population-based cohort study.

Background:The COVID-19 pandemic has led to an increase in telemedicine use. We compared care and outcomes in patients with transient ischemic attack (TIA) or minor ischemic stroke before and after the widespread adoption of telemedicine in Ontario, Canada, in 2020.Methods:In a population-based cohort study using linked administrative data, we identified patients with TIA or ischemic stroke discharged from any emergency department in Ontario before the widespread use of telemedicine (Apr. 1, 2015, to Mar. 31, 2020) and after (Apr. 1, 2020, to Mar. 31, 2021). We measured care, including visits with a physician, investigations and medication renewal. We compared 90-day death before and after 2020 using Cox proportional hazards models, and we compared 90-day admission using cause-specific hazard models.Results:We identified 47 601 patients (49.3% female; median age 73, interquartile range 62–82, yr) with TIA (n = 35 695, 75.0%) or ischemic stroke (n = 11 906, 25.0%). After 2020, 83.1% of patients had 1 or more telemedicine visit within 90 days of emergency department discharge, compared with 3.8% before. The overall access to outpatient visits within 90 days remained unchanged (92.9% before v. 94.0% after; risk difference 1.1, 95% confidence interval [CI] −1.3 to 3.5). Investigations and medication renewals were unchanged. Clinical outcomes were also similar before and after 2020; the adjusted hazard ratio was 0.97 (95% CI 0.91 to 1.04) for 90-day all-cause admission, 1.06 (95% CI 0.94 to 1.20) for stroke admission and 1.07 (95% CI 0.93 to 1.24) for death.Interpretation:Care and short-term outcomes after TIA or minor stroke remained stable after the widespread implementation of telemedicine during the COVID-19 pandemic. Our findings suggest that telemedicine is an effective method of health care delivery that can be complementary to in-person care for minor ischemic cerebrovascular events.

50 Hospital Admission Rates and Mortality Among Emergency Department Patients With COVID-19 Discharged With Remote Patient Monitoring With or Without HO2ME (home oxygen) – A Value-Based Approach

50 Hospital Admission Rates and Mortality Among Emergency Department Patients With COVID-19 Discharged With Remote Patient Monitoring With or Without HO2ME (home oxygen) – A Value-Based Approach

Short-term DAPT after coronary stenting has similar ischemic and bleeding outcomes as long-term DAPT: a 5-year population-based cohort study.

Optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) remains controversial. We investigated the relationship between DAPT duration following PCI and long-term ischemic and bleeding outcomes under real-world conditions. Patients aged ≥ 65years who underwent PCI with stenting in Western Australian hospitals between 2003 and 2008 and survived 2years were identified from linked hospital admissions data. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE) defined as a composite of all-cause death and admissions for acute coronary syndrome (ACS), coronary artery revascularization procedure, stroke, and major bleeding. Secondary outcomes were ACS admissions, all-cause death, and major bleeding admissions. Patients were followed up for 5years from initial PCI. A total of 3963 patients were included in the final analysis. The mean age of the cohort was 74.5 ± 6.1years with 67.3% males. No significant difference was seen with 6-12, 12-18, or 18-24months DAPT, compared to 0-6months DAPT duration for MACCE and all secondary outcomes at 3- and 5-year post-PCI. There is no significant difference in both bleeding and ischemic outcomes in long-term DAPT as compared to short-term DAPT for first- and second-generation drug-eluting stents in a real-world population.

Association of serum nitric oxide metabolite level with mortality in patients undergoing coronary angiography

BackgroundNitric oxide (NO) is a relevant molecule for vascular homeostasis. The level of serum NO metabolites (NOx), which consist of nitrite and nitrate, has been investigated as an alternative biomarker of NO production, but its clinical value has not yet been determined. Methods and results143 patients (66 ± 12 years old) were followed up after coronary catheterization. During a median (inter-quartile range) observation period of 6.13 (3.32–9.21) years, there were 20 (14 %) all-cause deaths, including 11 (8 %) cardiovascular deaths, 17 (12 %) major adverse cardiovascular events, and 17 (12 %) hospital admissions for heart failure. Median NOx level was 34.5 μmol/L (23.9–54.3). NOx was a risk factor for all-cause death [hazard ratio (HR) by unit increase, 1.010, 95 % confidence interval (CI) 1.001–1.018; p = 0.021] and heart failure (HR 1.010, CI 1.001–1.019; p = 0.029). Even after adjustment for age, sex, coronary risk factors, C-reactive protein, log-transformed brain natriuretic peptide, estimated glomerular filtration rate, and nitrate treatment, NOx was a risk factor for all-cause death (HR 1.015, CI 1.004–1.027; p = 0.008) and admission with heart failure (HR 1.018, CI 1.005–1.018, p = 0.007). ConclusionsAn increase in serum NOx level does not herald a benign clinical course but is an independent predictor of high risk of any-cause mortality and heart failure.

Multi-disciplinary community respiratory team management of patients with chronic respiratory illness during the COVID-19 pandemic

The Greater Glasgow & Clyde NHS Trust Community Respiratory Response Team was established to manage patients with chronic respiratory disease at home during the COVID-19 pandemic. The team aimed to avert hospital admission while maximally utilising remote consultations. This observational study analysed outcomes of the triage pathway used, use of remote consultations, hospital admissions and mortality among patients managed by the team. Patients’ electronic health records were retrospectively reviewed. Rates of emergency department attendance, hospital admission and death within 28 days of referral were compared across triage pathways. Segmented linear regression was carried out for emergency admissions in Greater Glasgow and Clyde pre- and post- Community Respiratory Response Team implementation, using emergency admissions for chronic obstructive pulmonary disease in the rest of Scotland as control and adjusting for all-cause emergency admissions. The triage category correlated with hospital admission and death. The red pathway had the highest proportion attending the emergency department (21%), significantly higher than the amber and green pathways (p = 0.03 and p = 0.004, respectively). The highest number of deaths were in the blue “end-of-life” pathway (p < 0.001). 87% of interactions were undertaken remotely. Triage severity appropriately led to targeted home visits. No nosocomial COVID-19 infections occurred among patients or staff. The Community Respiratory Response Team was associated with a significant decrease in emergency admissions (RR = 0.96 for each additional month under the Poisson model) compared to the counterfactual if the service had not been in place, suggesting a benefit in reducing secondary care pressures. The Community Respiratory Response Team effectively managed patients with chronic respiratory disease in the community, with an associated reduction in secondary care pressures during the COVID-19 pandemic.

All-cause admissions following a first ever exacerbation-related hospitalisation in COPD.

Hospital admissions are important contributors to the overall burden of chronic obstructive pulmonary disease (COPD). Understanding the patterns and causes of hospital admissions will help to identify targets for preventive interventions. This study aimed to determine the 5-year all-cause hospital admission trajectories of patients with COPD following their first ever exacerbation-related hospitalisation. Patients with COPD were identified from the Danish national registries. Patients experiencing their first ever exacerbation-related hospitalisation, defined as the index event, between 2000 and 2014 were included. All-cause hospital admissions were examined during a subsequent 5-year follow-up period, and categorised using the International Classification of Diseases, 10th revision. In total, 82 964 patients with COPD were included. The mean±sd age was 72±10 years and 48% were male. Comorbidities were present in 58%, and 65% of the patients collected inhalation medication ≤6 months prior to the index event. In total, 337 066 all-cause hospital admissions were identified, resulting in a 5-year admission rate of 82%. Most admissions were due to nonrespiratory causes (59%), amongst which cardiac events were most common (19%). Hospital admissions following a first exacerbation-related hospitalisation are common; nonrespiratory events constitute the majority of admissions. Besides the respiratory causes, treatment targeting the nonrespiratory causes of hospital admission should be considered to effectively decrease the burden of hospitalisation in COPD.

Relationships of Atrial Fibrillation at Diagnosis and Type of Atrial Fibrillation During Follow-up With Long-Term Outcomes for Heart Failure With Preserved Ejection Fraction.

Background: Few data are available regarding the impact of atrial fibrillation (AF) at diagnosis and type of AF during the follow-up period on long-term outcomes in patients with heart failure with preserved ejection fraction (HFpEF).Methods and Results: In all, 1,697 patients diagnosed as HFpEF between March 2010 and December 2017 were included in this study. At enrollment, 698 (41.1%) patients had AF. Over a median follow-up of 1,017 days, there were no significant differences between patients with and without AF in the adjusted hazard ratio (HR) for all-cause death or admission for heart failure. However, those with AF had a higher risk of stroke (HR 1.831; P=0.003). Of 998 patients with sinus rhythm at enrollment, 139 (13.9%) developed new-onset AF. Predictors of new-onset AF were pulse, hemoglobin, left ventricular end-diastolic dimension, and B-type natriuretic peptide. Compared with sinus rhythm, paroxysmal AF had a similar risk for all-cause death, admission for HF, and stroke; persistent AF had a lower risk of all-cause death (HR 0.701; P=0.015), but a higher risk for admission for HF (HR 1.608; P=0.002); and new-onset AF had a lower risk for all-cause death (HR 0.654; P=0.040), but a higher risk of admission for HF (HR 2.475; P<0.001).Conclusions: In patients with HFpEF, long-term outcome may differ by type of AF. Physicians need to consider individual risk with regard to AF type.

Safety and efficacy of ultrafiltration versus diuretics in patients with decompensated heart failure: A systematic review and meta-analysis

BackgroundUltrafiltration (UF) is used for fluid removal patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) refractory to diuretics. However, data on the relative merits of UF and diuretics are limited. MethodsOnline databases were queried to identify clinical trials on the comparison of UF and diuretics. The major adverse cardiovascular (MACE) and its components (mortality and re-hospitalizations) were compared using the random-effects model to calculate the unadjusted odds ratio (OR) with its 95% confidence interval (CI). ResultsA total of 10 clinical trials comprising 838 patients (413 UF, 425 diuretics) were included in the analysis. At a median follow-up of 90 days, there was no significant difference in the odds of MACE (OR 0.71, 95% CI 0.47–1.07) and all-cause mortality (OR 1.08, 95% CI 0.77–1.52) between patients undergoing UF compared with those receiving diuretics therapy. The need for emergency department visits (OR 1.05, 95% CI 0.38–2.90), all-cause admissions (OR 0.97, 95% CI 0.72–1.30) and heart failure-related re-hospitalization (OR 0.47, 95% CI 0.21–1.02) was also similar between the two groups. The in-hospital risk for hypotension (OR 0.49, 0.23–1.04) and post-therapy creatinine rise>0.3 mg/dL (OR 1.18, 95% CI 0.74–1.89) was also not significantly different between the UF and diuretics arms. A sensitivity analysis of MACE and mortality did not show any deviation from the pooled outcomes. ConclusionsIn patients with HFrEF, UF appears to be safe but might not provide significant benefits in terms of reducing the risk of mortality or readmission rates compared with those treated with diuretics.

Admissions of Children and Adolescents With Deliberate Self-harm to Intensive Care During the SARS-CoV-2 Outbreak in Australia

Identification of potential indirect outcomes associated with the COVID-19 pandemic in the pediatric population may be essential for understanding the challenges of the current global public health crisis for children and adolescents. To investigate whether the SARS-CoV-2 outbreak and subsequent effective public health measures in Australia were associated with an increase in admissions to intensive care units (ICUs) of children and adolescents with deliberate self-harm (DSH). This national, multicenter cohort study was conducted using the Australian data subset of the binational Australian and New Zealand Paediatric Intensive Care registry, a collaborative containing more than 200 000 medical records with continuous contributions from all 8 Australian specialist, university-affiliated pediatric ICUs, along with 1 combined neonatal-pediatric ICU and 14 general (adult) ICUs in Australia. The study period encompassed 6.5 years from January 1, 2015, to June 30, 2021. Patients aged 12 to 17 years were included. Data were analyzed from December 2021 through February 2022. Any of the following admission diagnoses: ingestion of a drug, ingestion of a nondrug, hanging or strangulation, or self-injury. The primary outcome measure was the temporal trend for national incidence of DSH ICU admissions per 1 million children and adolescents aged 12 to 17 years in Australia. A total of 813 children and adolescents aged 12 to 17 years admitted to ICUs with DSH were identified among 64 145 patients aged 0 to 17 years in the Australian subset of the registry during the study period. Median (IQR) age was 15.1 (14.3-15.8) years; there were 550 (67.7%) female patients, 261 (32.2%) male patients, and 2 (0.2%) patients with indeterminate sex. At the onset of the pandemic, monthly incidence of DSH ICU admissions per million children and adolescents increased from 7.2 admissions in March 2020 to a peak of 11.4 admissions by August 2020, constituting a significant break in the temporal trend (odds ratio of DSH ICU admissions on or after vs before March 2020, 4.84; 95% CI, 1.09 to 21.53; P = .04). This occurred while the rate of all-cause admissions to pediatric ICUs of children and adolescents of all ages (ie, ages 0-17 years) per 1 million children and adolescents decreased from a long-term monthly median (IQR) of 150.9 (138.1-159.8) admissions to 91.7 admissions in April 2020. This cohort study found that the coronavirus pandemic in Australia was associated with a significant increase in admissions of children and adolescents to intensive care with DSH.

Characterizing cancer and COVID-19 outcomes using electronic health records.

PurposePatients with cancer often have compromised immune system which can lead to worse COVID-19 outcomes. The purpose of this study is to assess the association between COVID-19 outcomes and existing cancer-specific characteristics.Patients and methodsPatients aged 18 or older with laboratory-confirmed COVID-19 between June 1, 2020, and December 31, 2020, were identified (n = 314 004) from the Optum® de-identified COVID-19 Electronic Health Record (EHR) derived from more than 700 hospitals and 7000 clinics in the United States. To allow sufficient observational time, patients with less than one year of medical history in the EHR dataset before their COVID-19 tests were excluded (n = 42 365). Assessed COVID-19 outcomes including all-cause 30-day mortality, hospitalization, ICU admission, and ventilator use, which were compared using relative risks (RRs) according to cancer status and treatments.ResultsAmong 271 639 patients with COVID-19, 18 460 had at least one cancer diagnosis: 8034 with a history of cancer and 10 426 with newly diagnosed cancer within one year of COVID-19 infection. Patients with a cancer diagnosis were older and more likely to be male, white, Medicare beneficiaries, and have higher prevalences of chronic conditions. Cancer patients had higher risks for 30-day mortality (RR 1.07, 95% CI 1.01–1.14, P = 0.028) and hospitalization (RR 1.04, 95% CI 1.01–1.07, P = 0.006) but without significant differences in ICU admission and ventilator use compared to non-cancer patients. Recent cancer diagnoses were associated with higher risks for worse COVID-19 outcomes (RR for mortality 1.17, 95% CI 1.08–1.25, P<0.001 and RR for hospitalization 1.10, 95% CI 1.06–1.14, P<0.001), particularly among recent metastatic (stage IV), hematological, liver and lung cancers compared with the non-cancer group. Among COVID-19 patients with recent cancer diagnosis, mortality was associated with chemotherapy or radiation treatments within 3 months before COVID-19. Age, black patients, Medicare recipients, South geographic region, cardiovascular, diabetes, liver, and renal diseases were also associated with increased mortality.Conclusions and relevanceIndividuals with cancer had higher risks for 30-day mortality and hospitalization after SARS-CoV-2 infection compared to patients without cancer. More specifically, patients with a cancer diagnosis within 1 year and those receiving active treatment were more vulnerable to worse COVID-19 outcomes.

Abstract 227: Long Term Outcomes In Patients With Type 2 Myocardial Infarction With And Without Significant Change In Troponin Levels

Background: It is well known that morbidity and mortality are higher in patients with Type 2 Myocardial Infarction (T2MI) compared to Type 1 MI. Few studies have compared outcomes in T2MI patients with significant increase in troponins (Tpn) (Myocardial infarction [Inf]) vs Tpn elevation with no or an insignificant Tpn increase (Myocardial Injury [Inj]). Method: Single center retrospective observational study evaluating patients admitted with an elevated Tpn-I and no evidence of obstructive coronary artery disease. Inj was defined as &lt;50% increase if Tpn-I ≤ 1.0 ng/mL or &lt;20% increase if Tpn-I &gt; 1.0 ng/mL. Inf was defined as Tpn increase ≥ 50% if Tpn-I ≤ 1.0 ng/mL or ≥ 20% increase if Tpn-I &gt; 1.0 ng/mL. Primary outcome was a composite of all-cause mortality, coronary revascularization, or admission for heart failure within 1 year. Results: The study included 3,123 patients with a hospital admission between March 2019 to September 2019: 1609 patients with Inj and 1514 patients with Inf. Adjusted primary outcome was higher with Inf than Inj (p=0.02), as was revascularization (p=0.0017). Readmission for heart failure was not significantly different (p=0.26). Risk factors for primary outcomes (history of stroke, diabetes, ESRD, hypertension, and heart failure) were higher in the Inj group with lower primary outcomes. (Table) Conclusion: Patients with T2MI (Inf pattern of Tpn) are more likely to have an adverse outcome within 1 year than patients with Inj. Clinical Implications: True T2MI (rise in Tpn) are more likely to have an adverse outcome and require catherization than patients with flat Tpn elevation who are more likely to have heart failure.

Associated comorbidities, healthcare utilization & mortality in hospitalized patients with haemophilia in the United States: Contemporary nationally representative estimates.

IntroductionCurrent in‐hospital burden and healthcare utilization patterns for persons with haemophilia (PWH) A and B, including both children (ages < 18 years) and adults (ages ≥ 18 years), in the United States (US) are lacking.AimTo evaluate healthcare utilization, the prevalence of comorbidities, and mortality in hospitalized paediatric and adult PWH using a contemporary nationally representative cohort.MethodsHospitalizations of PWH either as the primary reason for admission (principal diagnosis) or one of all listed diagnoses were identified using ICD‐10 codes from the 2017 Nationwide Inpatient Sample (NIS), the largest publicly available all‐payer inpatient discharge database in the US. Sampling weights were applied to generate nationally representative estimates.ResultsThe contemporary cohort included 10,555 hospitalizations (paediatrics, 18.3%; adults, 81.7%) among PWH as one‐of‐all listed diagnoses (n = 1465 as principal diagnosis). Median age (interquartile range) was 46 (24–66) years overall; adults, 54 (35–70) years and paediatric, 4 (1–11). The most common comorbidities in adults were hypertension (33.4%), hyperlipidaemia (23.6%), and diabetes (21.1%). In children, hemarthrosis (11.4%), contusions (9.6%), and central line infections (9.3%) were the most common. The overall mortality rate was 2.3%. Median hospital charges per haemophilia admission were $52,616 ($24,303–$135,814) compared to $26,841 ($12,969–$54,568) for all‐cause admissions in NIS.ConclusionBleeding and catheter‐related infections are the significant reasons for paediatric haemophilia admissions. Adult haemophilia admissions tend to be associated with age‐related comorbidities. Costs for haemophilia‐related hospitalizations are higher than the national average for all‐cause hospitalizations.

Outcomes Of Remote Pulmonary Artery Hemodynamic Monitoring In Heart Failure Patients With Atrial Fibrillation In Male And Female Population

Introduction Pulmonary artery (PA) hemodynamic monitoring using CadioMEMS device has shown to decrease heart failure (HF) readmissions. Atrial fibrillation (AFib) and HF often coexist and AFib can itself cause variations in PA pressures. We studied the impact of remote PA hemodynamic monitoring in reducing HF readmissions in patients with Afib and HF in male and female population. Method Retrospective data was collected for patients with HF who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. Data including number of all cause and HF hospitalizations, emergency department (ED) and HF clinic visits was collected for 1-year pre and 1-year post device implantation. Mortality data was collected at 1-year post-implantation. Analysis was done using the median and Kruskal-Wallis test for comparison between different age groups. Mortality was compared using Pearson's chi-squared test. Results CardioMEMS device was implanted in 177 patients during the study period. Of this population, 107 (60%) had AFib. There was a statistically significant decrease in overall mean HF admissions in Afib patients from 1.68 (± 1.34) to 0.63 (± 1.08), (63.1%) p<0.001 and mean HF ED visits 1.38 (± 1.40) to 0.57 (± 1.02), (58.7%) p<0.001 between 1-year pre and post implantation. But there was no statistically significant difference between male and female population in all-cause admissions, HF admissions, ED visits, ED HF visits, HF clinic visits along with mortality at 1-year post-implantation. Conclusion Remote PA hemodynamic monitoring decreases heart failure readmissions and ED visits in patients with AFib and HF and outcomes are similar in male and female population. Pulmonary artery (PA) hemodynamic monitoring using CadioMEMS device has shown to decrease heart failure (HF) readmissions. Atrial fibrillation (AFib) and HF often coexist and AFib can itself cause variations in PA pressures. We studied the impact of remote PA hemodynamic monitoring in reducing HF readmissions in patients with Afib and HF in male and female population. Retrospective data was collected for patients with HF who had CardioMEMS device implanted based on FDA indications from April 2015 to August 2020. Data including number of all cause and HF hospitalizations, emergency department (ED) and HF clinic visits was collected for 1-year pre and 1-year post device implantation. Mortality data was collected at 1-year post-implantation. Analysis was done using the median and Kruskal-Wallis test for comparison between different age groups. Mortality was compared using Pearson's chi-squared test. CardioMEMS device was implanted in 177 patients during the study period. Of this population, 107 (60%) had AFib. There was a statistically significant decrease in overall mean HF admissions in Afib patients from 1.68 (± 1.34) to 0.63 (± 1.08), (63.1%) p<0.001 and mean HF ED visits 1.38 (± 1.40) to 0.57 (± 1.02), (58.7%) p<0.001 between 1-year pre and post implantation. But there was no statistically significant difference between male and female population in all-cause admissions, HF admissions, ED visits, ED HF visits, HF clinic visits along with mortality at 1-year post-implantation. Remote PA hemodynamic monitoring decreases heart failure readmissions and ED visits in patients with AFib and HF and outcomes are similar in male and female population.

The association between immunosuppressants use and COVID-19 adverse outcomes: national COVID-19 cohort in South Korea.

There is uncertainty of the effect of immunosuppression, including corticosteroids, before COVID-19 infection on COVID-19 outcomes. The aim of this study was to investigate the relationship between prehospitalization immunosuppressants use (exposure) and COVID-19 patient outcomes. We conducted a population-based retrospective cohort study using a nationwide healthcare claims database of South Korea as of May 15, 2020. Confirmed COVID-19 infection in hospitalized individuals aged 40 years or older were included for analysis. We defined exposure variable by using inpatient and outpatient prescription records of immunosuppressants from the database. Our primary endpoint was a composite endpoint of all-cause death, intensive care unit (ICU) admission, and mechanical ventilation use. Inverse probability of treatment weighting (IPTW)-adjusted logistic regression analyses were used, to estimate odds ratio (OR) and 95% confidence intervals (CI), comparing immunosuppressants users and non-users. We identified 4,349 patients, for which 1,356 were immunosuppressants users and 2,993 were non-users. Patients who used immunosuppressants were at increased odds of the primary endpoint of all-cause death, ICU admission and mechanical ventilation use (IPTW OR =1.32; 95% CI: 1.06-1.63), driven by higher odds of all-cause mortality (IPTW OR =1.63; 95% CI: 1.21-2.26). Patients who used corticosteroids (n=1,340) were at increased odds of the primary endpoint (IPTW OR =1.33; 95% CI: 1.07-1.64). Immunosuppressant use was associated with worse outcomes among COVID-19 patients. These findings support the latest guidelines from the CDC that people on immunosuppressants are at high risk of severe COVID-19 and that immunocompromised people may benefit from booster COVID-19 vaccinations.

Association between prognosis and the use of angiotensin‐converting enzyme inhibitors and/or angiotensin II receptor blockers in frail patients with heart failure with preserved ejection fraction

AimsThe effectiveness of angiotensin‐converting enzyme inhibitors (ACE‐I) and angiotensin II receptor blockers (ARB) has not been demonstrated in patients with heart failure with preserved ejection fraction (HFpEF). We recently reported significant interaction between the use of ACE‐I and/or ARB (ACE‐I/ARB) and frailty on prognosis in patients with HFpEF. In the present study, we examined the association between ACE‐I/ARB and prognosis in patients with HFpEF stratified by the presence or absence of frailty.Methods and resultsWe examined the association between the use of ACE‐I/ARB and prognosis according to the presence [Clinical Frailty Scale (CFS) ≥ 5] or absence (CFS ≤ 4) of frailty in patients with HFpEF in a post hoc analysis of registry data. Primary endpoint was the composite of all‐cause mortality and heart failure admission. Secondary endpoints were all‐cause mortality and heart failure admission. Of 1059 patients, median age was 83 years and 45% were male. Kaplan–Meier analysis showed that the risk of composite endpoint (log‐rank P = 0.001) and all‐cause death (log‐rank P = 0.005) in patients with ACE‐I/ARB was lower in those with CFS ≥ 5, but similar between patients with and without ACE‐I/ARB in patients with CFS ≤ 4 (composite endpoint: log‐rank P = 0.830; all‐cause death: log‐rank P = 0.192). In a multivariable Cox proportional hazards model, use of ACE‐I/ARB was significantly associated with lower risk of the composite endpoint [hazard ratio (HR) = 0.52, 95% confidence interval (CI) = 0.33–0.83, P = 0.005] and heart failure admission (HR = 0.45, 95% CI = 0.25–0.83, P = 0.010) in patients with CFS ≥ 5, but not in patients with CFS ≤ 4 (composite endpoint: HR = 1.41, 95% CI = 0.99–2.02, P = 0.059; heart failure admission: HR = 1.43, 95% CI = 0.94–2.18, P = 0.091). The association between ACE‐I or ARB and prognosis did not significantly differ by CFS (CFS ≤ 4: log‐rank P = 0.562; CFS ≥ 5: log‐rank P = 0.100, for with ACE‐I vs. ARB, respectively). Adjusted HRs for CFS 1–4 were higher than 1.0 but were <1.0 at CFS 5.ConclusionsIn patients with HFpEF, use of ACE‐I/ARB was associated with better prognosis in patients with frailty as assessed with the CFS, but not in those without frailty.

Clinical significance of 123I-BMIPP washout rate in patients with uncertain chronic heart failure.

Recently, triglyceride deposit cardiomyovasculopathy (TGCV) with defective intracellular lipolysis was found to be a disease that causes heart failure. As a diagnostic criterion for TGCV, an Iodaine-123-β-methyl iodophenyl-pentadecanoic acid washout rate (BMIPP WOR) of < 10% is used, but its clinical significance in patients with heart failure remains to be clarified. In 62 hospitalized patients with chronic heart failure, 123I-BMIPP myocardial single-photon emission computed tomography (SPECT) was performed predischarge state. The prevalence of TGCV was investigated. Subsequently, follow-up was conducted for ≥ 90days (mean: 724.6 ± 392.7days), and the association between the BMIPP WOR and cardiac events was examined, establishing all-cause mortality and admission due to heart failure as endpoints. Of the 62 patients, the WOR was < 10% in 41 (66.1%). Of these, 26 (41.9%) were diagnosed with definite TGCV. Furthermore, cardiac events were noted in 12 patients (19.4%). Analysis with Cox proportional hazards models showed that the BMIPP WOR < 4.5% was a significant event-predicting factor [HR 4.29, 95% CI: 1.20-16.87; p = 0.0245]. On a Kaplan-Meier curve, the WOR was 4.5%; there was a significant difference in the incidence of events (p = 0.0298). In the predischarge state of heart failure, 123I-BMIPP myocardial SPECT was performed. In approximately 40% of the patients, a diagnosis of TGCV was made. The results suggested that the BMIPP WOR is useful for predicting the prognosis of chronic heart failure patients regardless of TGCV.

Increased risk of hospital admissions in patients with active systemic lupus erythematosus (SLE) classified according to two different SLE disease activity indices: a prospective cohort study.

The aim of this prospective cohort study was to investigate the risk of hospital admissions within one year in patients with active systemic lupus erythematosus (SLE), classified according to the Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS) or the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K). This study was conducted in adult patients with SLE recruited from the rheumatology outpatient department in a regional hospital in southern Taiwan. SLE disease activity was measured with SLE-DAS and SLEDAI-2K. The computerised patient record database was accessed to identify patients' hospital admissions. Cox regression analyses were used to estimate the hazard ratio (HR) for all-cause and SLE-related hospital admission in SLE patients classified by SLE-DAS and SLEDAI-2K. A total of 326 adult patients with SLE completed this study. All-cause and SLE-related hospital admissions within one year occurred in 17.5% and 12.6% of the patients, respectively. Results of the Cox regression analysis indicated that SLE patients with moderate/severe disease activity classified by the SLE-DAS (HR=2.43, p=0.005) but not moderate/severe disease activity classified by the SLEDAI-2K (HR=1.84, p=0.057) was significantly associated with the risk of SLE-related admissions. However, only moderate/severe disease activity classified by the SLE-DAS was significantly associated with the risk of all-cause admissions (HR=1.94, p=0.016). When steroid dosage was considered, only the steroid dosage was significantly associated all-cause and SLE-related admissions. In this study, SLE disease activity classified by SLE-DAS was significantly associated with an increased risk for both all-cause and SLE-related hospital admissions. Rheumatologists should be vigilant for increased risk of hospital admissions in patients with moderate/high SLE disease activity as classified by SLE-DAS.

Insulin Pump-related Inpatient Admissions in a National Sample of Youth With Type 1 Diabetes.

Insulin pump use in type 1 diabetes management has significantly increased in recent years, but we have few data on its impact on inpatient admissions for acute diabetes complications. We used the 2006, 2009, 2012, and 2019 Kids' Inpatient Database to identify all-cause type 1 diabetes hospital admissions in those with and without documented insulin pump use and insulin pump failure. We described differences in (1) prevalence of acute diabetes complications, (2) severity of illness during hospitalization and disposition after discharge, and (3) length of stay (LOS) and inpatient costs. We identified 228 474 all-cause admissions. Insulin pump use was documented in 7% of admissions, of which 20% were due to pump failure. The prevalence of diabetic ketoacidosis (DKA) was 47% in pump nonusers, 39% in pump users, and 60% in those with pump failure. Admissions for hyperglycemia without DKA, hypoglycemia, sepsis, and soft tissue infections were rare and similar across all groups. Admissions with pump failure had a higher proportion of admissions classified as major severity of illness (14.7%) but had the lowest LOS (1.60 days, 95% CI 1.55-1.65) and healthcare costs ($13 078, 95% CI $12 549-$13 608). Despite the increased prevalence of insulin pump in the United States, a minority of pediatric admissions documented insulin pump use, which may represent undercoding. DKA admission rates were lower among insulin pump users compared to pump nonusers. Improved accuracy in coding practices and other approaches to identify insulin pump users in administrative data are needed, as are interventions to mitigate risk for DKA.