Clinical Classification Software Research Articles

Analysis of Increased Blood Transfusions in U.S. Hospitals, 1997 – 2006.

Blood transfusion during hospitalization (Tx-hospitalization) in the U.S. is very common in medical practice. In-hospital blood transfusions are indicated for multiple medical, surgical and hemorrhagic conditions. However, descriptions of the patient populations receiving transfusions in U.S. hospitals are vague. The purpose of this study is to use nationally representative hospital discharge data to provide information regarding the patient populations and associated diagnoses that have caused the demand for blood transfusions in U.S. hospitals. Data were obtained through cross-sectional analysis of the 1997 through 2006 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS). The NIS is the largest, multi-year, all-payer inpatient care database that is publicly available in the U.S. The NIS contains data from 5 to 8 million unweighted hospital stays from about 1,000 hospitals sampled to approximate a 20-percent stratified sample of U.S. community hospitals. The NIS is drawn from the States participating in HCUP, which represent 90% of all hospital discharges in 2006. The NIS includes weights that allow calculation of reliable, representative national estimates of care in U.S hospitals. Blood transfusion was identified using the Clinical Classifications Software (CCS) procedure grouping 222. In 2006, 2.4 hospital hospitalizations included at least one blood product transfusion compared with 1.1 million in 1997. This 117% increase in Tx-hospitalizations was steady, with an average of 140,000 additional Tx-hospitalizations during each year. During that same period, the total number of U.S. hospitalizations increased 14%. Blood transfusions were among the top 10 procedures performed in all age groups. The elderly (>65+ years of age) accounted for the greatest number of hospitalizations with a transfusion with 1.4 million in 2006 compared to 622,000 in 1997. The most common type of transfusion was packed red cells, which accounted for about 90 percent of all types of transfusions (2.1 million of the 2.4 million transfusions in 2006). Coding of diagnosis at discharge was utilized to determine the conditions contributing to the increased utilization of transfusions. Transfusion was coded as a primary procedure during hospitalizations in which more invasive procedures were not performed. From 1997 to 2006, the fraction of hospitalizations with transfusion listed as the principle procedure was stable, and represented one-fourth of all Tx-hospitalizations. Within that group, the most common principle diagnoses were coded as anemia (15.8%), gastrointestinal hemorrhage (7.3%), CHF (5.5%), pneumonia (5.2%), and septicemia (5.0%). Cancers accounted for <1%. Transfusions were coded as a secondary procedure another invasive procedure occurred during the same hospitalization and represented the remaining three-fourths of cases. In that group, the most common principle diagnoses were osteoarthritis (8.3%), GI hemorrhage (6.5%), fracture of hip (5.1%), septicemia (4.3%), and complication of a device, implant or graft (4.2%). The most common principle procedures were UGI endoscopy (9.1%), hip replacement (6.0%), knee arthroscopy (6.0%) hip fracture repair (4.4%) and CABG (3.7%). In separate analyses, it was demonstrated that 20 percent of all hospitalizations for knee arthoplasty and 30 percent for hip replacement included a transfusion in 2006. In summary, hospital discharge data from the NIS provides critical and detailed clinical information on uses and trends of blood transfusions in U.S. hospitals. There has been a steady and significant increase in Tx-hospitalizations during the last decade that far exceeds the overall increase in hospitalizations (117% vs. 14%). A relatively small group of diagnoses including gastrointestinal bleeding and lower extremity arthroplasty represent one-third of the Tx-hospitalizations. Understanding the clinical demand for blood components in U.S. hospitals should facilitate optimal management of these limited and life-saving resources.

Abstract 4680: Rapid Growth in Hospitalizations for Adults with Congenital Heart Disease in the United States

Background: Adults with congenital heart disease (ACHD) constitute a growing population due to advances in pediatric care and diagnostic testing. This study aimed to better define the growth in ACHD hospitalizations and to provide data on the cost of hospitalization for these patients. Methods: We utilized data from the 1998 –2005 Nationwide Inpatient Survey, the largest all-payer nationally representative hospital discharge database, to analyze trends in ACHD hospitalizations. We included all patients over 17 years of age with Clinical Classification Software diagnostic code 213 (Cardiac and Circulatory Anomalies). National estimates of hospitalizations and hospital charges by year for ACHD diagnoses were calculated, as were equivalent estimates for specific subsets of patients. Results: The number of ACHD hospitalizations increased 67% between 1998 and 2005, from 53,212 to 88,610 per year. Over this period, the annual number of admissions increased for both simple (44,781 to 75,911) and complex diagnoses (8,431 to 12,699)(Table ). Patients 55 years or older made up approximately 51% of all ACHD patients, and 40% of those with complex disease. Rates of hospitalization increased similarly for patients under and over 55 years old among all diagnostic categories. Inpatient mortality decreased from 2.6+/−0.2% to 1.7+/−0.1% for simple diagnoses, and 4.4+/−0.5% to 3.7+/−0.4% for complex diagnoses. Mean hospital charges per hospitalization increased 66% from $21,485 to $35,565, and the estimated total national charges for these hospitalizations increased from $1.1 billion to $3.1 billion in 2005 (all in 1998 dollars). In 1998, admissions for ACHD accounted for 0.31% of estimated total national charges for hospitalizations of patients 18 years or older, as compared with 0.47% in 2005. Conclusions: There has been a striking increase in hospitalizations for ACHD, and the cost of these admissions is rising out of proportion to overall hospital costs. Number of Adult Congenital Heart Disease Admissions per Year

National estimation of rates of HIV serology testing in US emergency departments 1993–2005: baseline prior to the 2006 Centers for Disease Control and Prevention recommendations

The 2006 Centers for Disease Control and Prevention recommendations place increased emphasis on emergency departments (EDs) as one of the most important medical care settings for implementing routine HIV testing. No longitudinal estimates exist regarding national rates of HIV testing in EDs. We analyzed a nationally representative ED database to assess HIV testing rates and characterize patients who received HIV testing, prior to the release of the 2006 guidelines. A cross-sectional analysis of US ED visits (1993-2005) using the National Hospital Ambulatory Medical Care Survey was performed. Patients aged 13-64 years were included for analysis. Diagnoses were grouped with Healthcare Cost and Utilization Project Clinical Classifications Software. Analyses were performed using procedures for multiple-stage survey data. HIV testing was performed in an estimated 2.8 million ED visits (95% confidence interval, 2.4-3.2) or a rate of 3.2 per 1000 ED visits (95% confidence interval, 2.8-3.7). Patients aged 20-39 years, African-American, and Hispanic had the highest testing rates. Among those tested, leading reasons for visit were abdominal pain (9%), puncture wound/needlestick (8%), rape victim (6%), and fever (5%). The leading medication class prescribed was antimicrobials (32%). The leading ED diagnosis was injury/poisoning (30%) followed by infectious diseases (18%). Of note, 6% of those tested were diagnosed with HIV infection during their ED visits. Prior to the release of the 2006 Centers for Disease Control and Prevention guidelines for routine HIV testing in all healthcare settings, baseline national HIV testing rates in EDs were extremely low and appeared to be driven by clinical presentation.

Visual Loss After Spine Surgery

Retrospective cohort study using National inpatient sample administrative data. To determine national estimates of visual impairment and ischemic optic neuropathy after spine surgery. Loss of vision after spine surgery is rare but has devastating complications that has gained increasing recognition in the recent literature. National population-based studies of visual complications after spine surgery are lacking. All patients from 1993 to 2002 who underwent spine surgery (Clinical Classifications software procedure code: 3, 158) and who had ischemic optic neuropathy (ION) (ICD9-CM code 377.41), central retinal artery occlusion (CRAO) (ICD9-CM code 362.31) or non-ION, non-CRAO perioperative visual impairment (ICD9-CM codes: 369, 368.4, 368.8-9368.11-13) were included. Univariate and multivariate analysis were performed to identify potential risk factors. The overall incidence of visual disturbance after spine surgery was 0.094%. Spine surgery for scoliosis correction and posterior lumbar fusion had the highest rates of postoperative visual loss of 0.28% and 0.14% respectively. Pediatric patients (<18 years) were 5.8 times and elderly patients (>84 years) were 3.2 times more likely than, patients 18 to 44 years of age to develop non-ION, non-CRAO visual loss after spine surgery. Patients with peripheral vascular disease (OR = 2.0), hypertension (OR = 1.3), and those who received blood transfusion (OR = 2.2) were more likely to develop non-ION, non-CRAO vision loss after spine surgery. Ischemic optic neuropathy was present in 0.006% of patients. Hypotension (OR = 10.1), peripheral vascular disease (OR = 6.3) and anemia (OR = 5.9) were the strongest risk factors identified for the development of ION. We used multivariate analysis to identify significant risk factors for visual loss after spine surgery. National population-based estimate of visual impairment after spine surgery confirms that ophthalmic complications after spine surgery are rare. Since visual loss may be reversible in the early stages, awareness, evaluation and prompt management of this rare but potentially devastating complication is critical.

Comorbidity risk-adjustment strategies are comparable among persons with hip fracture

Objective To determine the magnitude and importance of declines in model performance associated with altering the data source and time frame from which comorbid conditions were identified in claims-based risk adjustment among persons with hip fracture. Study Design and Setting Medicare claims data were used to identify incident hip fracture cases in 1999. Three risk-adjustment instruments were evaluated: one by Iezzoni, the Charlson Index (Romano adaptation), and the Clinical Classification Software (CCS). Several implementation strategies, defined by altering data source (MedPar and/or Part B claims) and time frame (index hospitalization and/or 1-year preperiod), were assessed for each instrument. Logistic regression was used to predict 1-year mortality, and model performance was compared. Results Each instrument had modest ability to predict 1-year mortality after hip fracture. The CCS performed best overall ( c = 0.76), followed by the Iezzoni ( c = 0.73) and Charlson models ( c = 0.72). Although each instrument performed most favorably when applied to both inpatient and outpatient claims and when comorbidities were considered during the preperiod, varying data source and time frame had trivial effects on model performance. Conclusion The similar predictive ability of the three risk-adjustment instruments suggests that ease of implementation be a key consideration in choosing an approach for hip fracture populations.

Risk factors for pressure ulcers in acute care hospitals

Selection of patients for preventive measures to protect against pressure ulcers relies on clinical scales and provider judgment, which vary widely. Our objectives were to: (a) identify risk factors by clinical classification and report demographic differences in pressure ulcer risk and (b) develop criteria for identification of high-risk patients. Patients with pressure ulcer as a discharge diagnosis were identified from the 2003 Nationwide Inpatient Sample (NIS). The effect of discharge diagnosis was examined using the Agency for Healthcare Research and Quality Clinical Classification Software (CCS). Multiple regression analysis for survey data was used to assess risk factors. The 2003 NIS listed 94,758 with a discharge diagnosis of pressure ulcer, identified as International Classification of Disease-9 code 707.0-707.09, for an overall incidence of 143 per 10,000. Forty-five CCS discharge diagnoses were present in at least 5% of these patients and 28 of these CCS diagnoses had odds ratios >2.0. African-American race and advanced age were identified as risk factors for pressure ulcer diagnosis. Disorders of skin integrity, organ system failure, and infection were found to be broad categories of risk factors as well. Using the NIS, risk factors for pressure ulcer including diagnoses and demographic factors have been identified.

Sickle Cell Disease Mortality in the United States: Age at Death and Contributing Causes.

BACKGROUND: In the early 1990's, the Cooperative Study of Sickle Cell Disease (CSSCD) estimated a median life expectancy of 42 years for males, and 48 years for females with sickle cell anemia. We used death certificate data from the late 1990's and early 2000's to examine age at death and contributing causes of death for persons with sickle cell disease (SCD).METHODS: We used the National Center for Health Statistics Multiple Cause of Death (MCOD) files to examine age at death and contributing causes of death for persons in the U.S. with SCD during the years 1999 to 2004. The MCOD files contain data from all death certificates filed in the U.S. Each observation in the data has listed an underlying (primary) cause of death, as well as up to 20 conditions thought to contribute to the death. We used ICD-10 codes D570-D578 to identify all deaths attributed to SCD during the time period under study. Records with the ICD-10 code for sickle cell trait (D573) were excluded from further analyses. We used the Clinical Classification Software provided by the Healthcare Cost and Utilization Project to collapse all listed ICD-10 codes into smaller categories. Analyses of age at death were conducted using t-tests, median tests, ANOVA, and multiple linear regression as appropriate.RESULTS: From 1999 to 2004, there were 4553 deaths in the U.S. attributed to SCD (mean = 759/yr, sd = 42.6). SCD was listed as the primary cause in 65% of the deaths. 95% of the deaths were attributed to HbSS disease, and approximately 1% of the deaths were attributed to double heterozygous sickle cell disorders (SC/SD/SE/Thal). 50.4% of the deaths were among males. 64% of the decedents had a high school education or less. 54% of the decedents lived in the South. 68% of the decedents died as inpatients in a hospital. The mean age at death for the time period was 38.2 years (sd = 15.6). There was no change in the mean age at death during the time period. Females were older than males at death (39.4 vs. 36.9, p < 0.0001). Those with HbSS were younger than those with a double heterozygous disorder (38 vs. 47, p < 0.02). Having SCD listed as the primary cause of death was associated with younger age at death (36.8 vs. 40.7, p < 0.0001). Decedents with at least some college education were older at death than those with high school educations or less (40.9 vs. 37.0 p < 0.0001). There were no regional differences in mean age at death. In a multivariate model of age at death with the predictors gender, region, education, and whether or not SCD was listed as the primary cause of death, being female and having some college education remained associated with older age at death, while having SCD listed as the primary cause of death remained associated with younger age at death. Septicemia, pulmonary heart disease, liver disease and renal failure were among the top contributing causes of death for adults, while septicemia, acute cerebrovascular disease and pneumonia were among the top contributing causes of death for kids.CONCLUSIONS: Persons dying from SCD during 1999 to 2004 experienced ages at death that are not improved over those reported by the CSSCD, suggesting the continued need for societal efforts aimed at improving the quality of care for SCD, especially among adults with the condition. Educational attainment is associated with age at death among the SCD population, though it is not possible from the cross-sectional nature of this data to determine the causal directionality of this association.

Regression Tree Boosting to Adjust Health Care Cost Predictions for Diagnostic Mix

To assess the ability of regression tree boosting to risk-adjust health care cost predictions, using diagnostic groups and demographic variables as inputs. Systems for risk-adjusting health care cost, described in the literature, have consistently employed deterministic models to account for interactions among diagnostic groups, simplifying their statistical representation, but sacrificing potentially useful information. An alternative is to use a statistical learning algorithm such as regression tree boosting that systematically searches the data for consequential interactions, which it automatically incorporates into a risk-adjustment model that is customized to the population under study. Administrative data for over 2 million enrollees in indemnity, preferred provider organization (PPO), and point-of-service (POS) plans from Thomson Medstat's Commercial Claims and Encounters database. The Agency for Healthcare Research and Quality's Clinical Classification Software (CCS) was used to sort 2001 diagnoses into 260 diagnosis categories (DCs). For each plan type (indemnity, PPO, and POS), boosted regression trees and main effects linear models were fitted to predict concurrent (2001) and prospective (2002) total health care cost per patient, given DCs and demographic variables. Regression tree boosting explained 49.7-52.1 percent of concurrent cost variance and 15.2-17.7 percent of prospective cost variance in independent test samples. Corresponding results for main effects linear models were 42.5-47.6 percent and 14.2-16.6 percent. The combination of regression tree boosting and a diagnostic grouping scheme, such as CCS, represents a competitive alternative to risk-adjustment systems that use complex deterministic models to account for interactions among diagnostic groups.

Rural Versus Urban Inpatient Case-Mix Differences in the US

Preparation of surgeons for practice in rural settings is hindered by limited knowledge of case-mix differences between rural and nonrural surgical practices. Although surgical practice in isolated rural areas is believed to be very different from urban practice, little is known about actual inpatient case-mix differences. We performed a retrospective, descriptive comparison of inpatient general surgical procedures performed at rural versus urban hospitals in the US using the Nationwide Inpatient Sample database (2000 to 2001). Rural versus urban geographic designations were based on Rural-Urban Commuting Area codes developed by the Rural Health Research Institute. Inpatient surgical procedures were aggregated by the Clinical Classifications Software based on ICD-9-CM procedure codes. Operations on the bowel, appendix, and gallbladder constitute 61% of general surgical inpatient procedures in rural hospitals, compared with 46% in urban hospitals. Compared with urban general surgery practices, rural practices include substantially fewer operations on the stomach and esophagus (6% versus 11%), liver and pancreas (0% versus 1%), spleen and thyroid (3% versus 10%), and bowel (17% versus 19%). General surgical procedures constitute 42% of inpatient procedures in rural hospitals versus 25% in urban hospitals. A rural general surgeon more broadly trained in selected obstetric and gynecologic operations could potentially perform 66% of all inpatient procedures in rural hospitals. Addition of simple vascular cases (eg, arteriovenous fistula, vascular access), head and neck operations, amputations, and nephrectomies could increase this potential to 71% of all cases. Rural and urban general surgical inpatient case-mixes differ from each other substantially. Additional competence in a few surgical areas that are not currently emphasized in general surgical training could result in an increased role for general surgeons practicing in rural areas.

Cost Analysis and Cost Determinants in a European Inflammatory Bowel Disease Inception Cohort With 10 Years of Follow-up Evaluation

Economic analysis in chronic diseases is a prerequisite for planning a proper distribution of health care resources. We aimed to determine the cost of inflammatory bowel disease, a lifetime illness with considerable morbidity. We studied 1321 patients from an inception cohort in 8 European countries and Israel over 10 years. Data on consumption of resources were obtained retrospectively. The cost of health care was calculated from the use of resources and their median prices. Data were analyzed using regression models based on the generalized estimating equations approach. The mean annual total expenditure on health care was 1871 Euro/patient-year for inflammatory bowel disease, 1524 Euro/patient-year for ulcerative colitis, and 2548 Euro/patient-year for Crohn's disease (P < .001). The most expensive resources were medical and surgical hospitalizations, together accounting for 63% of the cost in Crohn's disease and 45% in ulcerative colitis. Total and hospitalization costs were much higher in the first year after diagnosis than in subsequent years. Differences in medical and surgical hospitalizations were the primary cause of substantial intercountry variations of cost; the mean cost of health care was 3705 Euro/patient-year in Denmark and 888 Euro/patient-year in Norway. The outlay for mesalamine, a costly medication with extensive use, was greater than for all other drugs combined. Patient age at diagnosis and sex did not affect costs. In this multinational, population-based, time-dependent characterization of the health care cost of inflammatory bowel disease, increased expenditure was driven largely by country, diagnosis, hospitalization, and follow-up year.

Admission to acute care hospitals for adolescent substance abuse: a national descriptive analysis

BackgroundUse of alcohol and illicit drugs by adolescents remains a problem in the U.S. Case identification and early treatment can occur within a broad variety of healthcare and non-healthcare settings, including acute care hospitals. The objective of this study is to describe the extent and nature of adolescent admissions to the acute inpatient setting for substance abuse (SA). We use the Agency for Healthcare Research and Quality (AHRQ) 2000 Healthcare Cost and Utilization Project Kids Inpatient Database (HCUP-KID) which includes over 2.5 million admissions for youth age 20 and under to 2,784 hospitals in 27 states in the year 2000. Specifically, this analysis estimates national number of admissions, mean total charges, and mean lengths of stay for adolescents between the ages of 12 and 17 admitted to an acute care hospital for the following diagnostic categories from the AHRQ's Clinical Classifications Software categories: "alcohol-related mental disorders" and "substance-related mental disorders". Frequency and percentage of total admissions were calculated for demographic variables of age, gender and income and for hospital characteristic variables of urban/rural designation and children's hospital designation.ResultsSA admissions represented 1.25 percent of adolescent admissions to acute care hospitals. Nearly 90 percent of the admission occurred in non-Children's hospitals. Most were for drug dependence (38%) or non-dependent use of alcohol or drugs (35%). Costs were highest for drug dependence admissions. Nearly half of admissions had comorbid mental health diagnoses. Higher rates of admission were seen in boys, in older adolescents, and in "self-pay" patients. Alcohol and drug rehabilitation/detoxification, alone or in combination with psychological and psychiatric evaluation and therapy, was documented for 38 percent of admissions. Over 50 percent of cases had no documentation of treatment specific to substance use behavior.ConclusionGeneral acute care hospitals have a significant and important opportunity to recognize, treat, and refer adolescents with substance abuse problems. These results suggest that inpatient facilities should develop and implement policies and processes to ensure that adolescent substance abusers admitted to their institutions receive appropriate care during the admission and appropriate referral to community care resources.

Common Reasons for Hospitalization Among Adult Patients with Diabetes

To determine reasons for hospitalization among adult patients with diabetes. A cross-sectional analysis was conducted of hospital discharges in the state of Georgia for the years 1998 through 2001 that contained either a primary or a coexisting diagnosis of diabetes. With use of the Clinical Classification Software of the Agency for Healthcare Research and Quality, the principal diagnoses among diabetes-related hospital discharges were organized into diagnostic categories. Diabetes was listed as a diagnosis in 14% of all Georgia hospital discharges of adult patients during our study period (57% women; 62% non-Hispanic white; mean age, 64 years; mean length of stay, 5.7 days; and mean hospital charge, 13,540 dollars). Among patients with a diagnosis of diabetes, the 3 most common categories of discharges were "diseases of the circulatory system" (33%), "endocrine, nutritional, and metabolic; immunity disorders" (13%), and "diseases of the respiratory system: (11%). When infections were identified and aggregated, however, these conditions became the second most frequent discharge category (14% of all hospital discharges among patients with diabetes). "Congestive heart failure," "coronary atherosclerosis," and "acute myocardial infarction" were the first, second, and fifth most frequently found unique diagnoses, respectively, among patients with diabetes. In this study, diseases of the circulatory system were the most common diagnoses in hospital discharge data for adult patients with diabetes in Georgia. Hospitals should be cognizant of the increased burden placed on them by diabetes, and outpatient treatment of diabetes should focus on prevention of cardiovascular diseases to avoid hospitalizations.

National Estimates of Hospital Use by Children With HIV Infection in the United States: Analysis of Data From the 2000 KIDS Inpatient Database

The purpose of this research was to describe hospital use patterns of HIV-infected children in the United States. We analyzed a nationwide, stratified probability sample of 2.5 million hospital discharges of children and adolescents during the year 2000, weighted to 7.3 million discharges nationally. We excluded discharges after hospitalizations related to pregnancy/childbirth and their complications and discharges of neonates <1 month of age and of patients >18 years of age. Diagnoses were identified through the use of the Clinical Classification Software with grouping of related diagnoses. We estimated that there were 4107 hospitalizations of HIV-infected children in 2000 and that these hospitalizations accounted for approximately dollar 100 million in hospital charges and >30000 hospital days. Infections, including sepsis and pneumonia, were among the most frequent diagnoses in such hospitalizations, followed by diagnoses related to gastrointestinal conditions, nutritional deficiencies and anemia, fluid/electrolyte disorders, central nervous system disorders, cardiovascular disorders, and respiratory illnesses. Compared with hospitalizations of non-HIV-infected children, hospitalizations of HIV-infected ones were more likely to be in urban areas, in pediatric/teaching hospitals, and in the Northeast, and the expected payer was more likely to be Medicaid (77.6% vs 37.2%). Compared with children without HIV, those with HIV tended to be older (median age: 9.5 years vs 5.2 years), to have been hospitalized longer (mean: 7.8 days vs 3.9 days), and to have incurred higher hospital costs (mean: dollar 23221 vs dollar 11215); HIV-associated hospitalizations ended in the patient's death more frequently than non-HIV ones (1.8% vs 0.4%), and complications of medical care were also more common (10.8% vs 6.2%). Infections account for the majority of hospitalizations of HIV-infected children in the United States, although nutritional deficiencies, anemia and other hematologic disorders, gastrointestinal and renal disorders, and complications of medical care are also more common among hospitalized children with HIV than among those without HIV.

Clinical and Economic Outcomes of Hospital Acquired Pneumonia in Intra-Abdominal Surgery Patients

To measure the clinical and economic impact of postoperative hospital-acquired pneumonia (HAP) and to identify risk factors for the development of HAP. Although postoperative HAP is recognized to be an major risk associated with surgery, little is known about the overall outcomes of patients whose hospital stay is complicated by HAP following surgery. We studied 618,495 patients who underwent an intra-abdominal operation from the National Inpatient Sample database over a 1-year period (January 2000 to December 2000) using CPT codes and discharge diagnoses identified by the Clinical Classification Software. Data collected included demographic characteristics, type of operation, in-hospital mortality, discharge disposition, length of stay, and hospital charges. Of the 13,292 patients with HAP following intra-abdominal surgery, 1421 died prior to discharge (mortality = 10.7%) compared with 7217 deaths in the control group of patients without HAP following intra-abdominal surgery (mortality = 1.2%) (P < 0.001). HAP was independently associated with a 4.13-fold (95% confidence interval = 3.94-4.34) increase in risk to be discharged to a skilled nursing facility. The mean length of hospital stay for intra-abdominal patients who developed HAP was significantly greater compared with intra-abdominal surgery patients who did not develop HAP (17.10 days versus 6.07 days, P < 0.001). After adjusting for patient characteristics, HAP was independently associated with a 75% (28,160.95 dollars; 95% confidence interval, 27,543.76 dollars - 28,778.13 dollars) mean increase in total hospital charges. Given the high incidence and significant impact of HAP on patient outcomes, early preventive strategies and interventions to reduce HAP should be a priority.

Common Reasons for Hospitalization in Urban Diabetes Patients

Determine principal reasons for hospitalization in a predominantly urban, African American diabetes patient population. Data for outpatients with a diagnosis of diabetes were abstracted from electronic records. The number of hospitalizations from 1998 through 2001 was determined after linking our dataset with a statewide discharge dataset. Principal diagnoses were grouped into 18 multilevel diagnostic classes using the Agency for Healthcare Research and Quality's Clinical Classifications Software. A total of 6505 unique patients had 20,344 discharges from 1998 through 2001; 92% were listed as African Americans and 61% as women. Frequency of each multilevel diagnostic class and the most commonly occurring diagnoses. The most common multilevel diagnostic classes were "diseases of the circulatory system" (29.0% of all discharges) and "endocrine, nutritional, and metabolic; immunity disorders" (17.1%). The five most commonly occurring unique diagnoses were "congestive heart failure," "diabetes with ketoacidosis or uncontrolled diabetes," "coronary atherosclerosis," "diabetes with other manifestations," and "pneumonia, organism unspecified." Nearly 16% of all discharged patients had diagnoses related to infection. The five most frequent diagnoses related to infection were "pneumonia, organism unspecified," "urinary tract infection, site not specified," "infection and inflammation, internal prosthetic device," "cellulitis and abscess of leg," and "postoperative infection." In this predominantly urban, African American diabetes patient population, potentially preventable hospitalizations involving diseases such as congestive heart failure and diabetes occur with high frequency. Better understanding of the risk factors underlying these hospitalizations--particularly those involving modifiable metabolic variables--requires further investigation.

Resource use of elderly emergency department patients with alcohol-related diagnoses

This study evaluates resource use associated with alcohol-related admissions through the emergency department (ED) by older adults. Data from 11 states were extracted from the Healthcare Cost and Utilization Project State Inpatient Databases. The study results revealed that the presence of a secondary alcohol-related diagnosis significantly increased resource use (37–119% for length of stay and 126–343% for charges; p < .05) associated with the top 10 International Classification of Diseases, Ninth Revision, Clinical Modification Clinical Classifications Software diagnoses. They also showed that admissions with an alcohol-related primary diagnosis had lower associated charges ($2,172; p < .05) and longer lengths of stay (0.3 days; p < .05) than other types of ED admissions. Proper linkages to substance abuse treatment services should be instituted and coupled with medical treatment to limit the additional resource use burden of alcohol-related admissions.

Using GIS in government: an overview of the VHA's Healthcare Atlas, FY-2000.

The amount of VA data available for analysis can be overwhelming to individuals who need to translate these data into usable information. The Atlas, using current GIS technology, was funded to provide data in a comprehensive guide. Patients were identified using a disease classification scheme based on Kaiser Permanente methodology and the Clinical Classifications Software (AHRQ). Utilization data were extracted from the Medical SAS Datasets. Cost data were obtained from the HERC. GIS tools were used to create the Atlas. The Atlas overviews the location of VA hospitals; profiles veteran, VA enrollee and patient populations; examines overall utilization; depicts patterns in healthcare use by specific disease cohorts; and examines geographic variations in costs. This product will enhance knowledge of VA's enrolled patient population and their healthcare needs, and provide background information that will improve the formulation of specific research questions to address those needs.

National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 kids' inpatient database

Objectives To identify and to generate national estimates of the principal gastrointestinal (GI) diagnoses associated with hospital utilization and to describe national hospital utilization patterns associated with pediatric GI disorders. Study design We analyzed a nationwide and stratified probability sample of 1.9 million hospital discharges from 1997 of children 18 years and younger, weighted to 6.7 million discharges nationally. Principal GI diagnoses were identified through the use of the Clinical Classification Software and Major Diagnostic Categories. Results In 1997 in the United States, there were 329,825 pediatric discharges associated with a principal GI diagnosis, accounting for more than $2.6 billion in hospital charges and more than 1.1 million hospital days. Appendicitis, intestinal infection, noninfectious gastroenteritis, abdominal pain, esophageal disorders, and digestive congenital anomalies combined accounted for 75.1% of GI discharge diagnoses, 64.2% of GI hospital charges, and 68.0% of GI hospital days. Excluding normal newborn infants and conditions related to pregnancy, GI disorders were the third leading cause of hospitalization. Conclusions GI disorders are a leading cause of hospitalization of children. A minority of GI conditions account for the majority of measures of utilization. Children are hospitalized for GI conditions and at institutions that are distinct from adults.

The Endothelin-1 Antagonist, Atrasentan, Improves Time to Progression and Quality of Life in Hormone-Refractory Prostate Cancer

We describe age, multiple chronic condition profiles and health system contact in patients with urological cancer.Using Geisinger Health System electronic health records we identified adult primary care patients and a subset with at least 1 urology encounter between 2001 and 2015. The Agency for Health Care Research and Quality Chronic Condition Indicator and Clinical Classifications Software tools were applied to ICD-9 codes to identify chronic conditions. Multiple chronic conditions were defined as 2 or more chronic conditions. Patients with urological cancer were identified using ICD-9 codes for prostate, bladder, kidney, testis and penile cancer. Inpatient and outpatient visits in the year prior to the most recent encounter were counted to document health system contact.We identified 357,100 primary care and 33,079 urology patients, of whom 4,023 had urological cancer. Patients with urological cancer were older than primary care patients (71 vs 46 years) and they had more median chronic conditions (7 vs 4). Kidney and bladder cancer were the most common chronic conditions (median 8 patients each). Coronary artery disease and chronic kidney disease were common in urological cancer cases compared to mental health conditions in primary care cases. Patients with urological cancer who had multiple chronic conditions had the most health system contact, including 32% with at least 1 hospitalization and 68% with more than 5 outpatient visits during 1 year.Urology patients are older and more medically complex, especially those with urological cancer than primary care patients. These data may inform care redesign to reduce the treatment burden and improve care coordination in urological cancer cases.

Annual Report on Access to and Utilization of Health Care for Children and Youth in the United States–1999

The dynamics of health care delivery for children and adolescents have greatly evolved over the last 5 years. The growth of managed care has been especially rapid, and has coincided with other fundamental changes—declines in private coverage, growth of Medicaid, welfare reform, and the creation of the state Child Health Insurance Program (CHIP).1 Over the past 10 years, the number of children covered through employer-sponsored plans and other private plans has dropped.2 During this same period, changes to Medicaid have begun to de-couple eligibility from welfare eligibility, theoretically enabling states to expand coverage. For children, this movement from private to public coverage has accelerated the movement to managed care systems. Between 1991 and 1997, Medicaid enrollment in managed care plans increased from 9.5% to 47.8% of total Medicaid enrollment.3 Recent estimates suggest that over half of these Medicaid managed care enrollees are children.4 However, little is known about the impact of these trends on children's access to and use of services, let alone the quality and outcomes of that care. This report is the first in what is anticipated to be an annual series of reports on access to and use of health care services by America's children and youth. The report capitalizes on the existence of 2 national datasets, the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP), which have not been widely used by the child health services research community. As background to these new sources of data, we have provided a detailed description of the datasets, and review some of the fundamental tabulations. In future years, as more data are accumulated, these reports will focus on delineation of key trends and analyses addressing policy issues. ### MEPS The MEPS is conducted to provide nationally representative estimates of health care use, …