German Nationwide Inpatient Sample Research Articles

Incidence and impact of venous thromboembolism in hospitalized patients with acute pancreatitis

BackgroundAcute pancreatitis (AP) and venous thromboembolism (VTE) remain common and potentially lethal disease entities. AP might be an important trigger of systemic inflammtion and may activate the coagulation system with increased VTE risk. MethodsThe German nationwide inpatient sample was screened for patients admitted due to AP (ICD-code K85) 2005–2019. AP hospitalizations were stratified for VTE as well as risk-factors and the impact of VTE on in-hospital case-fatality rate were investigated. ResultsOverall, 797,364 hospitalizations of patients due to AP (aged in median 56.0 [IQR 44.0–71.0] years), 39.2 % females) were detected in Germany 2005–2019. Incidence of VTE in hospitalized AP patients was 1764.8 per 100,000 hospitalizations (1.8 %) with highest VTE rate between 5th and 6th decade. Cancer (OR 1.656 [95 %CI 1.513–1.812], P < 0.001), any surgery (OR 4.063 [95 %CI 3.854–4.284], P < 0.001), and heart failure (OR 1.723 [95 %CI 1.619–1.833], P < 0.001) were independently associated with VTE occurrence. Case-fatality (8.8 % vs. 2.7 %, P < 0.001) was more than 3-fold higher in AP patients with than without VTE. VTE was associated with increased case-fatality in AP patients (OR 3.925 [95 %CI 3.684–4.181], P < 0.001). ConclusionsVTE is a life-threatening event in hospitalized AP patients associated with an almost 4-fold increased case-fatality rate. Cancer, any surgery, thrombophilia and heart failure were important risk factors for occurrence of VTE in AP.

Risk factors for intensive care admission in pediatric patients with COVID-19 - results of the German na-tionwide inpatient sample

Abstract Funding Acknowledgements None. Background In December 2019 first patient-cases of pneumonia caused by an unknown virus were detected in Wuhan, China. From this day on, SARS-CoV-2 spread throughout the world with an enormous pace causing the deadliest pandemic of the twenty-first century. First infection cases in Germany were reported at the end of January 2020 in Bavaria and sustained transmission of SARS-CoV-2 resulted also in Germany in a strong spread of COVID-19 in the population. Although children and young people aged ≤18 years represent approximately 2%-5% of the SARS-CoV-2 cases globally, research efforts regarding COVID-19 pandemic have mainly focused on disease course of adults. Thus, early identification of children who must be monitored for life-threatening severe COVID-19 course remains difficult. Understanding of risk factors for ICU admission as one important bottleneck of adequate management regarding escalated treatment of COVID-19 pandemic is of outstanding interest to understand determinants, which are both crucial factors for adequate health care planning, decision making and pandemic management. Purpose We aimed to close this gap with identification of associated factors with pediatric ICU admissions in Germany. Methods We used the German nationwide inpatient sample analysing all hospitalised children ≤18 years with confirmed COVID-19 diagnosis in Germany between January 1st and December 31st, 2020 stratified fur ICU admission (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2020, own calculations). Results Overall, 3,360 cases of hospitalised children ≤18 years with COVID-19 infection were diagnosed in Germany 2020 (median age 7.0 [IQR 0.0-15.0] years, 49.8% of female sex); among them 4.3% had to be admitted on ICU. In-hospital death occurred in five patients with and three without ICU admission (3.5% vs. 0.1%, P&amp;lt;0.001) and ICU admission was independently associated with increased case-fatality (OR 21.573 [95%CI 4.191-111.044], P&amp;lt;0.001). Obesity (OR 3.419 [95%CI 1.300-8.993], P=0.013), diabetes mellitus (OR 6.929 [95%CI 3.327-14.432], P&amp;lt;0.001), pneumonia (OR 7.373 [95%CI 4.823-11.271], P&amp;lt;0.001), ARDS (OR 48.058 [95%CI 11.689-197.588], P&amp;lt;0.001) and multi-segmental Inflammatory syndrome caused by COVID-19 (OR 9.573 [95%CI 3.036-30.191], P&amp;lt;0.001), heart failure (OR 64.509 [95%CI 24.462-170.121], P&amp;lt;0.001), myocarditis (OR 4.682 [95%CI 1.278-17.149], P=0.020), acute and/or chronic kidney failure (OR 7.946 [95%CI 3.606-17.508], P&amp;lt;0.001), cancer (OR 5.220 [95%CI 2.599-10.485], P&amp;lt;0.001) and liver diseases (OR 5.501 [95%CI 2.177-13.899], P&amp;lt;0.001) were associated with ICU admission. Conclusions The proportion of hospitalized paediatric COVID-19 patients admitted on ICU in Germany was low with 4.3% accompanied by 3.5% case-fatality rate. Independent factors for ICU admission comprised cardio-vascular risk factors, comorbidities and complications of COVID-19.

Outcome of Pulmonary Embolism with and without Ischemic Stroke.

Background: Ischemic stroke is the second, and pulmonary embolism (PE) is the third most common cardiovascular cause of death after myocardial infarction. Data regarding risk factors for ischemic stroke in patients with acute PE are limited. Methods: Patients were selected by screening the German nationwide in-patient sample for PE (ICD-code I26) and were stratified by ischemic stroke (ICD code I63) and compared. Results: The nationwide in-patient sample comprised 346,586 hospitalized PE patients (53.3% females) in Germany from 2011 to 2014; among these, 6704 (1.9%) patients had additionally an ischemic stroke. PE patients with ischemic stroke had a higher in-hospital mortality rate than those without (28.9% vs. 14.5%, p < 0.001). Ischemic stroke was independently associated with in-hospital death (OR 2.424, 95%CI 2.278-2.579, p < 0.001). Deep venous thrombosis and/or thrombophlebitis (DVT) combined with heart septal defect (OR 24.714 [95%CI 20.693-29.517], p < 0.001) as well as atrial fibrillation/flutter (OR 2.060 [95%CI 1.943-2.183], p < 0.001) were independent risk factors for stroke in PE patients. Systemic thrombolysis was associated with a better survival in PE patients with ischemic thrombolysis who underwent cardio-pulmonary resuscitation (CPR, OR 0.55 [95%CI 0.36-0.84], p = 0.006). Conclusions: Ischemic stroke did negatively affect the survival of PE. Combination of DVT and heart septal defect and atrial fibrillation/flutter were strong and independent risk factors for ischemic stroke in PE patients. In PE patients with ischemic stroke, who had to underwent CPR, systemic thrombolysis was associated with improved survival.

Categorization of Patients With Pulmonary Embolism by Charlson Comorbidity Index

BackgroundShort-term outcomes of pulmonary embolism are closely related to right ventricular dysfunction and patient's hemodynamic status, but also to individual comorbidity profile. However, the impact of patients’ comorbidities on survival during pulmonary embolism might be underrated. Although the Charlson Comorbidity Index (CCI) is the most extensively studied comorbidity index for detecting comorbidity burden, studies analyzing the impact of CCI on pulmonary embolism patients’ survival are limited. MethodsWe used the German nationwide inpatient sample to analyze all hospitalized patients with pulmonary embolism in Germany 2005-2020 and calculated CCI for each patient, compared the CCI classes (very low: CCI = 0 points, mild: CCI = 1-2 points, moderate: CCI = 3-4, high severity: CCI >4 points) and impact of CCI class on outcomes. ResultsOverall, 1,373,145 hospitalizations of patients with acute pulmonary embolism (53.0% females, 55.9% aged ≥70 years) were recorded in Germany between 2005 and 2020; the CCI class stratified them. Among these, 100,156 (7.3%) were categorized as very low; 221,545 (16.1%) as mild; 394,965 (28.8%) as moderate; and 656,479 (47.8%) as patients with a high comorbidity burden according to CCI class. In-hospital case fatality increased depending on the CCI class: 3.6% in very low, 6.5% in mild, 12.1% in moderate, and 22.1% in high CCI class (P < .001). CCI class was associated with increased in-hospital case fatality (odds ratio 2.014; 95% confidence interval, 2.000-2.027; P < .001). ConclusionOur study results may help practitioners to better understand and measure the association between an aggravated comorbidity profile and increased in-hospital case fatality in patients with pulmonary embolism.

Prevalence and Prognostic Role of Lymphedema in Patients with Deep Venous Thrombosis and Thrombophlebitis.

Background: Deep venous thrombosis (DVT) poses a substantial disease burden. Lymphedema may present with similar symptoms making the diagnosis process more difficult. Data on the epidemiology of lymphedema are lacking. Methods: The German nationwide inpatient sample served to analyze all patients hospitalized owing to DVT and/or thrombophlebitis (referred to as DVT) of the legs in Germany between 2005 and 2020. We stratified these patients for additional lymphedema and analyzed the impact of lymphedema on adverse in-hospital events. Results: Overall, 1,136,574 hospitalizations related to DVT were recorded in Germany during 2005-2020 (53.3% women; 51.3% aged ≥70 years). Lymphedema was coded in 9974 (0.9%) patient-cases (82.0% not elsewhere classified, 17.7% secondary lymphedema). Annual numbers of hospitalizations with lymphedema among DVT patients increased from 450 (2005) to 613 (2016) (β 0.57; 95% confidence interval [CI]: 0.48-0.66], p < 0.001) and decreased thereafter. Despite similar age, DVT patients with lymphedema had higher prevalence of cardiovascular diseases, chronic organ failure, and all types of investigated cancer. Prevalence of pulmonary embolism (PE) with shock/CPR (4.1% vs. 1.5%), acute renal failure (6.7% vs. 2.5%), and stroke (5.2% vs. 4.2%) was higher in DVT patients with lymphedema than without. Lymphedema was independently associated with PE with shock/CPR (OR: 2.1; 95% CI: 1.9-2.3) as well as death (OR: 1.3; 95% CI: 1.2-1.4). Conclusions: Comorbidity conditions like cancer, obesity, and cardiovascular risk factors, and also infectious complications, were more prevalent in DVT patients with lymphedema than in those without. Lymphedema was independently associated with severe in-hospital complications, particularly when its genesis was related to severe comorbidities.

Comorbidity burden assessed by the charlson comorbidity index and its influence on prognosis of patients with pulmonary embolism

Abstract Background Pulmonary embolism (PE) is an acute cardiovascular syndrome and can be associated with high morbidity and mortality. Short-term outcomes of PE are closely related to right ventricular dysfunction (RVD) and the patient’s haemodynamic status as well as age and comorbidity profile. According to the current ESC guidelines for management of acute PE patients, initial risk stratification is based on clinical symptoms and signs, whereby haemodynamic instability indicates a high-risk status with substantial increase of the risk for early death. However, the vast majority of PE patients are haemodynamically stable at presentation; they require further risk stratification with clinical, imaging, and laboratory indicators of PE severity as well as the patient’s comorbidity profile and other aggravating conditions. The pulmonary embolism severity index (PESI) and the simplified pulmonary embolism severity index (sPESI) are implemented for risk stratification in the ESC guidelines. However, other tools may be more suitable for characterizing the comorbidity profile of PE patients. One established approach to evaluate the comorbidity profile is the Charlson Comorbidity Index. Purpose The objective of the present study is to investigate the impact of the comorbid profile on prognosis of patients with acute PE in a large nationwide inpatient sample. Methods We used the German nationwide inpatient sample to analyse the Charlson Comorbidity Index score of all hospitalised patients with PE in Germany 2005-2020 (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005-2020, own calculations). The patients were categorized in the very-low severity (Charlson Comorbidity Index 0 points, mild severity (Charlson Comorbidity Index 1-2 points), moderate severity (Charlson Comorbidity Index 3-4 points) and severe severity (Charlson Comorbidity Index &amp;gt;4 points) and severity classes were compared. Results Overall, 1,373,145 hospitalizations of patients with acute PE (53.0% females, 55.9% aged ≥70years) were recorded in Germany between 2005 and 2020; they were stratified by the Charlson Comorbidity Index class. Among these, 100,156 (7.3%) were categorized as very-low, 221,545; (16.1%) as mild, 394,965 (28.8%) as moderate, and 656,479 (47.8%) as patients with a severe comorbidity burden. In-hospital case-fatality increased with the current Charlson Comorbidity Index class: 3.6% in very-low, 6.5% in mild, 12.1% in moderate and 22.1% in the severe Charlson Comorbidity Index class (P&amp;lt;0.001). The Charlson Comorbidity Index class was associated with increased in-hospital case-fatality (OR 2.014 [95%CI 2.000-2.027], P&amp;lt;0.001). Conclusion The results of our study may help to better understand and measure the association between an aggravated comorbidity profile and increased in-hospital case-fatality in patients with acute PE.

Incidence and risk factors of myocarditis in hospitalized patients with COVID-19 in Germany

Abstract Background In December 2019 first patient cases of pneumonia caused by a previously unknown virus was detected in China. This began the coronavirus disease 2019 (COVID-19)-pandemic with a never seen infectious disease burden and impact on the healthcare systems worldwide. The first severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections in Germany were reported on January 27th, 2020. From this initial cluster (in Bavaria), a sustained transmission of SARS-CoV-2 was followed by a substantial spread of COVID-19 in the German population. Although COVID-19 is frequently accompanied by symptoms like fever, cough, sore throat, malaise, myalgias, and dyspnoea, and the infection affects the lungs primarily, COVID-19 might also lead to acute cardiac, kidney, and liver injury. Cardiac complications, particularly myocarditis, and pericarditis, were associated with SARS-CoV-2 infection. Viral infections are frequent causes of myocarditis, an inflammation of the myocardium, which may result in hospitalization and heart failure and can be followed by sudden cardiac death. Myocarditis as cardiac involvement in COVID-19 infection is well known. Real-world data about incidence in hospitalized COVID-19 patients and risk factors for myocarditis in COVID-19 patients are sparse. Methods We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19-diagnosis in Germany in 2020 and stratified them for myocarditis (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2020, own calculations). Results Overall, 176,137 hospitalizations (52.3%males, 53.6%aged≥70years) with confirmed COVID-19-infection were coded in Germany in 2020, and among them, 226 (0.01%) had myocarditis (incidence:1.28 per 1000 hospitalization cases). Absolute numbers of myocarditis increased, while relative numbers decreased with age. COVID-19 patients with myocarditis were younger (64.0 [IQR 43.0/78.0] vs.71.0 [56.0/82.0], P&amp;lt;0.001). In-hospital case fatality was 1.3-fold higher in COVID-19 patients with than without myocarditis (24.3% vs. 18.9%, P=0.012). Myocarditis was independently associated with increased case fatality (OR 1.89 [95%CI 1.33-2.67], P&amp;lt;0.001). Independent risk factors for myocarditis were age&amp;lt;70years (OR 2.36 [95%CI 1.72-3.24], P&amp;lt;0.001), male sex (1.68 [95%CI 1.28-2.23], P&amp;lt;0.001), pneumonia (OR 1.77 [95%CI 1.30-2.42], P&amp;lt;0.001) and multi-systemic inflammatory COVID-19-infection (OR 10.73 [95%CI 5.39-21.39], P&amp;lt;0.001). Conclusion The incidence of myocarditis in hospitalized COVID-19 patients in Germany was 1.28 cases per 1000 hospitalizations in 2020. Risk factors for myocarditis in COVID-19 were young age, male sex, pneumonia, and multi-systemic inflammatory COVID-19 infection. Myocarditis was independently associated with increased case fatality.

Abstract 15011: Recent Trends in Interventional Treatment of Acute Pulmonary Embolism and Their Implications for a National Healthcare System

Introduction: Catheter-directed treatment (CDT) of acute pulmonary embolism (PE) is gaining popularity in Europe, following a trend that originated earlier in the US. For healthcare systems, reimbursement of CDT depends on their clinical benefits along with assessing the impact on hospital costs. Hypothesis-Aims: To estimate how increasing use of CDT, as reflected by prospective US data, may affect costs of PE treatment in the German hospital remuneration system (G-DRG). Methods: We analyzed data from the German nationwide inpatient sample (Federal Statistical Office), covering all hospitalizations for PE, for the years 2018-2019. For the same period, we analyzed prospective patient-level data from the multicenter US registry of the Pulmonary Embolism Response Team (PERT) Consortium. Results: During the study period, 196,167 patients were hospitalized for acute PE in Germany. Of these, 64,056 (33%) had intermediate-risk or high-risk PE, but overall ≤ 1% received CDT. Median reimbursement was є3,572 (IQR, 2,804-5,869), corresponding to є4,088 in inflation-adjusted 2022 currency ($5,678, adjusted for purchase parity power). Of 1,349 patients with intermediate- or high-risk PE included in the US registry in 2018-2019, 284 (21%) received CDT, mostly aspiration thrombectomy (63/1,349; 4.7%), ultrasound-assisted catheter thrombolysis (151; 11.2%), or non-assisted catheter thrombolysis (47; 3.5%). Median length of stay was 4.5 (2.8-8.2) days. Based on current reimbursement rates in the G-DRG, fees for PE treated with aspiration thrombectomy amount to є12,179-15,753, and for catheter-directed thrombolysis (with or without ultrasound) to є9,858-13,829. Considering, (a) the shorter length of stay; (b) the proportion of patients receiving CDT in the elevated-risk US cohort in 2018-19; and (c) that of intermediate- and high-risk PE in the German PE inpatient sample, average remuneration per patient would rise from currently є4,088 to є4,724 ($6,552). Conclusions: CDT for PE patients at elevated risk would currently lead to a 16% increase in average per-patient hospital costs in Germany. Together with clinical validation of CDT in ongoing studies, these estimates may inform decision making on reimbursement of interventional treatment options.

Air pollution impacts on in-hospital case-fatality rate of ischemic stroke patients

BackgroundA growing body of evidence suggests that air pollution exposure is associated with an increased risk for cardiovascular diseases. Data regarding the impact of long-term air pollution exposure on ischemic stroke mortality are sparse. MethodsThe German nationwide inpatient sample was used to analyse all cases of hospitalized patients with ischemic stroke in Germany 2015–2019, which were stratified according to their residency. Data of the German Federal Environmental Agency regarding average values of air pollutants were assessed from 2015 to 2019 at district-level. Data were combined and the impact of different air pollution parameters on in-hospital case-fatality was analyzed. ResultsOverall, 1,505,496 hospitalizations of patients with ischemic stroke (47.7% females; 67.4 % ≥70 years old) were counted in Germany 2015–2019, of whom 8.2 % died during hospitalization. When comparing patients with residency in federal districts with high vs. low long-term air pollution, enhanced levels of benzene (OR 1.082 [95%CI 1.034–1.132],P = 0.001), ozone (O3, OR 1.123 [95%CI 1.070–1.178],P < 0.001), nitric oxide (NO, OR 1.076 [95%CI 1.027–1.127],P = 0.002) and PM2.5 fine particulate matter concentrations (OR 1.126 [95%CI 1.074–1.180],P < 0.001) were significantly associated with increased case-fatality independent from age, sex, cardiovascular risk-factors, comorbidities, and revascularization treatments. Conversely, enhanced carbon monoxide, nitrogen dioxide, PM10, and sulphur dioxide (SO2) concentrations were not significantly associated with stroke mortality. However, SO2−concentrations were significantly associated with stroke-case-fatality rate of >8 % independent of residence area-type and area use (OR 1.518 [95%CI 1.012–2.278],P = 0.044). ConclusionElevated long-term air pollution levels in residential areas in Germany, notably of benzene, O3, NO, SO2, and PM2.5, were associated with increased stroke mortality of patients. Research in contextEvidence before this study:Besides typical, established risk factors, increasing evidence suggests that air pollution is an important and growing risk factor for stroke events, estimated to be responsible for approximately 14 % of all stroke-associated deaths. However, real-world data regarding the impact of long-term exposure to air pollution on stroke mortality are sparse.Added value of this study:The present study demonstrates that the long-term exposure to the air pollutants benzene, O3, NO, SO2 and PM2.5 are independently associated with increased case-fatality of hospitalized patients with ischemic stroke in Germany.Implications of all the available evidence:The results of our study support the urgent need to reduce the exposure to air pollution by tightening emission controls to reduce the stroke burden and stroke mortality.

Incidence and risk factors of myocarditis in hospitalized patients with COVID-19.

Myocarditis as cardiac involvement in COVID-19-infection is well known. Real-world data about incidence in hospitalized COVID-19-patients and risk factors for myocarditis in COVID-19-patients are sparse. We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19-diagnosis in Germany in 2020 and stratified them for myocarditis. Overall, 176,137 hospitalizations (52.3%males, 53.6%aged≥70years) with confirmed COVID-19-infection were coded in Germany in 2020 and among them, 226 (0.01%) had myocarditis (incidence:1.28 per 1000 hospitalization-cases). Absolute numbers of myocarditis increased, while relative numbers decreased with age. COVID-19-patients with myocarditis were younger (64.0 [IQR 43.0/78.0] vs.71.0 [56.0/82.0], P<0.001). In-hospital case-fatality was 1.3-fold higher in COVID-19-patients with than without myocarditis (24.3% vs. 18.9%, P=0.012). Myocarditis was independently associated with increased case-fatality (OR 1.89 [95%CI 1.33-2.67], P<0.001). Independent risk factors for myocarditis were age<70years (OR 2.36 [95%CI 1.72-3.24], P<0.001), male sex (1.68 [95%CI 1.28-2.23], P<0.001), pneumonia (OR 1.77 [95%CI 1.30-2.42], P<0.001) and multi-systemic inflammatory COVID-19-infection (OR 10.73 [95%CI 5.39-21.39], P<0.001). The incidence of myocarditis in hospitalized COVID-19-patients in Germany was 1.28 cases per 1000 hospitalizations in 2020. Risk factors for myocarditis in COVID-19 were young age, male sex, pneumonia, and multi-systemic inflammatory COVID-19-infection. Myocarditis was independently associated with increased case-fatality. This article is protected by copyright. All rights reserved.

Predisposing factors for admission to intensive care units of patients with COVID-19 infection-Results of the German nationwide inpatient sample.

Intensive care units (ICU) capacities are one of the most critical determinants in health-care management of the COVID-19 pandemic. Therefore, we aimed to analyze the ICU-admission and case-fatality rate as well as characteristics and outcomes of patient admitted to ICU in order to identify predictors and associated conditions for worsening and case-fatality in this critical ill patient-group. We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19 diagnosis in Germany between January and December 2020. All hospitalized patients with confirmed COVID-19 infection during the year 2020 were included in the present study and were stratified according ICU-admission. Overall, 176,137 hospitalizations of patients with COVID-19-infection (52.3% males; 53.6% aged ≥70 years) were reported in Germany during 2020. Among them, 27,053 (15.4%) were treated in ICU. COVID-19-patients treated on ICU were younger [70.0 (interquartile range (IQR) 59.0-79.0) vs. 72.0 (IQR 55.0-82.0) years, P < 0.001], more often males (66.3 vs. 48.8%, P < 0.001), had more frequently cardiovascular diseases (CVD) and cardiovascular risk-factors with increased in-hospital case-fatality (38.4 vs. 14.2%, P < 0.001). ICU-admission was independently associated with in-hospital death [OR 5.49 (95% CI 5.30-5.68), P < 0.001]. Male sex [OR 1.96 (95% CI 1.90-2.01), P < 0.001], obesity [OR 2.20 (95% CI 2.10-2.31), P < 0.001], diabetes mellitus [OR 1.48 (95% CI 1.44-1.53), P < 0.001], atrial fibrillation/flutter [OR 1.57 (95% CI 1.51-1.62), P < 0.001], and heart failure [OR 1.72 (95% CI 1.66-1.78), P < 0.001] were independently associated with ICU-admission. During 2020, 15.4% of the hospitalized COVID-19-patients were treated on ICUs with high case-fatality. Male sex, CVD and cardiovascular risk-factors were independent risk-factors for ICU admission.

CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism

Pulmonary embolism (PE) is accompanied by high morbidity and mortality. The search for simple and easily assessable risk stratification scores with favourable effectiveness is still ongoing, and prognostic performance of the CRB-65 score in PE might promising. The German nationwide inpatient sample was used for this study. All patient cases of patients with PE in Germany 2005-2020 were included and stratified for CRB-65 risk class: low-risk group (CRB-65-score 0 points) vs. high-risk group (CRB-65-score ≥1 points). Overall, 1,373,145 patient cases of patients with PE (76.6% aged ≥65 years, 47.0% females) were included. Among these, 1,051,244 patient cases (76.6%) were classified as high-risk according to CRB-65 score (≥1 points). The majority of high-risk patients according to CRB-65 score were females (55.8%). Additionally, high-risk patients according to CRB-65 score showed an aggravated comorbidity profile with increased Charlson comorbidity index (5.0 [IQR 4.0-7.0] vs. 2.0 [0.0-3.0], p < 0.001). In-hospital case fatality (19.0% vs. 3.4%, p < 0.001) and MACCE (22.4% vs. 5.1%, p < 0.001) occurred distinctly more often in PE patients of the high-risk group according to CRB-65 score (≥1 points) compared to the low-risk group (= 0 points). The CRB-65 high-risk class was independently associated with in-hospital death (OR 5.53 [95%CI 5.40-5.65], p < 0.001) as well as MACCE (OR 4.31 [95%CI 4.23-4.40], p < 0.001). Risk stratification with CRB-65 score was helpful for identifying PE patients being at higher risk of adverse in-hospital events. The high-risk class according to CRB-65 score (≥1 points) was independently associated with a 5.5-fold increased occurrence of in-hospital death.

Incidence and impact of venous thromboembolism in hospitalized patients with Crohn-disease

Abstract Background Prevalence of Crohn's disease (CD) is high in North America and in Europe ranging between 100 and 350 patient-cases per 100,000 citizens. CD is characterized by chronic inflammation with a progressive course and is often associated with different intestinal as well as extra-intestinal complications. CD is associated with both, other inflammatory diseases such as ankylosing spondylitis and psoriasis as well as venous thromboembolism (VTE). CD causes an activation of coagulation system, which might be the main reason for an increased risk of thromboembolic complications. Beside previous study results regarding higher VTE risk of patients with CD in comparison to the general population, particularly, data on impact of VTE on survival and risk factors for the occurrence of VTE in CD are sparse. Purpose The objectives of our study were to provide evidence about the current and past prevalence of VTE events in hospitalized patients with CD and to investigate the impact of VTE on outcomes of CD patients. Methods The German nationwide inpatient sample was screened for patients admitted due to CD (ICD-code K50) (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, own calculations). CD hospitalizations were stratified for VTE and risk factors for VTE and impact of VTE on in-hospital case-fatality rate were investigated. Results Overall, 333,975 patients-cases with hospital admissions due to CD were counted in Germany (median age 38.0 [IQR 24.0–52.0] years, 56.0% females) during the observational period between 2005 and 2018. VTE rate increased slightly from 0.6% to 0.7% (β 0.000097 [95% CI 0.000027 to 0.000167], P=0.007) from 2005 to 2018 and with age-decade of life (β 0.0017 [95% CI 0.0016 to 0.0019], P&amp;lt;0.001). In total, 0.7% (n=2,295) of the CD inpatients had an event of VTE. Patients with VTE were in median 12 years older (49.0 [34.0–62.0] vs. 37.0 [24.0–52.0] years, P&amp;lt;0.001) and CD colon-manifestations were more prevalent in those patients (32.0% vs. 27.7%, P&amp;lt;0.001). Age ≥70 years, obesity, colon-involvement, cancer, surgery, thrombophilia, and heart failure were strongly associated with higher risk of VTE in CD patients. In-hospital death occurred 15-times more often in CD with VTE than without (4.5% vs. 0.3%, P&amp;lt;0.001). VTE was independently associated with substantially increased in-hospital case-fatality rate (OR 9.31 [95% CI 7.54–11.50], P&amp;lt;0.001). Conclusions VTE is a life-threatening event in hospitalized CD patients associated with 9.3-fold increased case-fatality rate. Older age, obesity, colon involvement, cancer, surgery, thrombophilia and heart failure were strong risk factors for VTE in patients with CD. Funding Acknowledgement Type of funding sources: None.

Trends and risk factors of in-hospital mortality of patients with COVID-19 in Germany

Abstract Background Unselected data of nationwide studies of hospitalized patients with COVID-19 is still sparse, but these data are of outstanding interest not to exceed hospital capacities and to avoid overloading of national health-care systems. Purpose Thus, we sought to analyze seasonal/regional trends, predictors of in-hospital case-fatality and mechanical ventilation (MV) in patients with COVID-19 in Germany. Methods We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19 diagnosis in Germany between January 1st and December 31st in 2020 (source: RDC of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2020, own calculations). Covid-19-inpatients with MV vs. without MV and survivors vs. non-survivors were compared. Logistic regression models were calculated to investigate associations between patients' characteristics as well as adverse events and i) necessity of MV and ii) in-hospital death. Results We analyzed data of 176,137 hospitalizations of patients with confirmed COVID-19-infection. Among those, 31,607 (17.9%) died, whereby in-hospital case-fatality grew exponentially with age. Cardiovascular comorbidities were common in hospitalized patients with confirmed COVID-19-infections: Overall, almost half of the patients (46.8%; n=82,480) had arterial hypertension and 25,574 (14.4%) had a diagnosis of coronary artery disease. In 60.7% (n=106,913) of the hospitalizations, pneumonia was reported, 8.6% (n=15,061) had an acute infection of the upper or lower airways other than pneumonia, and 6.6% (n=11,594) suffered from an acute respiratory distress syndrome (ARDS) during hospitalization Age ≥70 years (OR 5.91, 95% CI 5.70–6.13, P&amp;lt;0.001), pneumonia (OR 4.58, 95% CI 4.42–4.74, P&amp;lt;0.001) and acute respiratory distress syndrome (OR 8.51, 95% CI 8.12–8.92, P&amp;lt;0.001) were strong predictors of in-hospital death. Most COVID-19-patients were treated in hospitals in urban areas (n=92,971) associated with lowest case-fatality (17.5%) as compared to hospitals in suburban (18.3%) or rural areas (18.8%). MV demand was highest in November/December 2020 (32.3%, 20.3%) in patients between 6th and 8th age-decade. In the first age-decade, 78 of 1861 children (4.2%) with COVID-19-infection were treated with MV and five of them died (0.3%). Conclusion The results of our study indicate seasonal and regional variations concerning number of COVID-19-patients, necessity of MV and case-fatality in Germany. These findings may help to ensure flexible allocation of intensive care (human) resources, which is essential for managing enormous societal challenges worldwide to avoid overloaded regional health-care systems. Funding Acknowledgement Type of funding sources: None.

COVID-19 infection and its impact on case-fatality in patients with pulmonary embolism

Abstract Background Although a high prevalence of pulmonary embolism (PE) has been reported as a complication during severe COVID-19 infections in critical ill patients, nationwide data of hospitalized patients with COVID-19 with PE is still limited. Thus, we sought to analyze seasonal trends and predictors of in-hospital case-fatality in patients with COVID-19 and PE in Germany. Methods We used the German nationwide inpatient sample to analyze all data on hospitalizations for COVID-19 patients with and without PE in Germany during the year 2020 and to compare changes of PE prevalence to 2019. Results We analyzed data of 176,137 hospitalizations because of COVID-19 in 2020. Among those, PE was recorded in 1.9% (n=3,362) of discharge or death certificates. Almost one third of patients with COVID-19 and PE died during the in-hospital course (28.7%). The case-fatality rate increased with patients' age peaking in the 9th life-decade. Regardless of COVID-19, 196,203 inpatients were diagnosed with PE in Germany between 2019 and 2020. The number of PE hospitalizations were widely equally distributed between both years (98,485 vs. 97,718), while the case-fatality rate of all patients with PE was slightly lower in 2019 compared to 2020 (12.7% vs. 13.1%, P&amp;lt;0.001). In contrast, considerable differences in prevalence and case-fatality were demonstrated in 2020 regarding PE patients with and without COVID-19 infection (28.7% vs. 13.1%, P&amp;lt;0.001) (Figure 1). A COVID-19-infection was associated with a 2.8-fold increased risk of case-fatality in patients with PE (OR 2.81, 95% CI 1.66–2.12, P&amp;lt;0.001). Conclusions In Germany, the prevalence of PE events complicating hospitalizations was similar in 2019 and 2020. However, the fatality rate among patients with COVID-19-associated PE was substantially higher than that in those without either COVID-19 or PE, indicating an additive prognostic effect of these two conditions. Funding Acknowledgement Type of funding sources: None.

Incidence and impact of venous thromboembolism in hospitalized patients with Crohn's disease

BackgroundCrohn's disease (CD) is associated with an increased risk for venous thromboembolism (VTE). Beside higher VTE risk, data on impact of VTE on survival and risk factors for the occurrence of VTE in CD are sparse. MethodsThe German nationwide inpatient sample was screened for patients admitted due to CD (ICD-code K50). CD hospitalizations were stratified for VTE and risk-factors for VTE and impact of VTE on in-hospital case-fatality rate were investigated. ResultsOverall, 333,975 hospitalizations of patients due to CD were counted in Germany (median age 38.0 [IQR 24.0–52.0] years, 56.0 % females) during the observational period 2005–2018. VTE rate increased slightly from 0.6 % (2005) to 0.7 % (2018) (β 0.000097 [95%CI 0.000027 to 0.000167], P = 0.007) 2005–2018 and with age-decade (β 0.0017 [95%CI 0.0016 to 0.0019], P < 0.001). In total, 0.7 % (2295) of the CD inpatients had a VTE event. Patients with VTE were in median 12 years older (49.0 [34.0–62.0] vs. 37.0 [24.0–52.0] years, P < 0.001) and colon-involvement was in those patients more prevalent (32.0 % vs.27.7 %, P < 0.001). Age ≥ 70 years, obesity, colon-involvement, cancer, surgery, thrombophilia, and heart failure were strongly associated with higher risk of VTE in CD patients.In-hospital death occurred 15-times more often in CD with VTE than without (4.5 % vs. 0.3 %, P < 0.001). VTE was independently associated with increased in-hospital case-fatality rate (OR 9.31 [95%CI 7.54–11.50], P < 0.001). ConclusionsVTE is a life-threatening event in hospitalized CD patients associated with 9.3-fold increased case-fatality rate. Older age, obesity, colon involvement, cancer, surgery, thrombophilia and heart failure were strong risk factors for VTE in CD.

COVID-19 infection and its impact on case fatality in patients with pulmonary embolism.

BackgroundAlthough a high prevalence of pulmonary embolism (PE) has been reported in association with coronavirus disease (COVID)-19 in critically ill patients, nationwide data on the outcome of hospitalised patients with COVID-19 and PE is still limited. Thus, we investigated seasonal trends and predictors of in-hospital death in patients with COVID-19 and PE in Germany.MethodsWe used the German nationwide inpatient sample to analyse data on hospitalisations among COVID-19 patients with and without PE during 2020, and to detect changes in PE prevalence and case fatality in comparison to 2019.ResultsWe analysed 176,137 COVID-19 hospitalisations in 2020; PE was recorded in 1.9% (n=3362) of discharge certificates. Almost one third of patients with COVID-19 and PE died during the in-hospital course (28.7%) compared to COVID-19 patients without PE (17.7%). Between 2019 and 2020, numbers of PE-related hospitalisations were largely unchanged (98,485 versus 97,718), whereas the case-fatality rate of PE increased slightly in 2020 (from 12.7% to 13.1%, p<0.001). Differences in case fatality were found between PE patients with and without COVID-19 in 2020 (28.7% versus 12.5%, p<0.001), corresponding to a 3.1-fold increased risk of PE-related death (OR 3.16, 95% CI 2.91–3.42, p<0.001) in the presence of COVID-19.ConclusionsIn Germany, the prevalence of PE events during hospitalisations was similar in 2019 and 2020. However, the fatality rate among patients with both COVID-19 and PE was substantially higher than that in those with only one of these diseases, suggesting a life-threatening additive prognostic impact of the COVID-PE combination.

Case-Fatality and Temporal Trends in Patients with Psoriasis and End-Stage Renal Disease.

Background and Objectives: During the last decades, growing evidence corroborates that chronic inflammatory disease impairs the body beyond the cutaneous barrier. Linkage between psoriasis and kidney disease, and in particular between psoriasis and end-stage renal disease (ESRD), have not yet been elucidated. We sought to analyze the impact of concomitant psoriasis on the in-hospital outcomes of patients hospitalized with ESRD. Patients and Methods: We analyzed data on characteristics, comorbidities, and in-hospital outcomes of all hospitalized patients with ESRD stratified for concomitant psoriasis in the German nationwide in-patient sample between 2010 and 2020. Results: Overall, 360,980 hospitalizations of patients treated for ESRD in German hospitals were identified from 2010 to 2020 and among these 1063 patients (0.3%) additionally suffered from psoriasis. While the annual number of all ESRD patients increased within this time, the number of patients with ESRD and the additional psoriasis diagnosis decreased slightly. Patients with ESRD and psoriasis were five years younger (66 [IQR, 56–75] vs. 71 [59–79] years, p < 0.001), were more often obese (17.5% vs. 8.2%, p < 0.001) and more frequently had cancer (4.9% vs. 3.3%, p < 0.001), diabetes mellitus (42.7% vs. 38.5%, p = 0.005) and coronary artery disease (31.1% vs. 28.0%, p = 0.026). Multivariate regression models demonstrated that psoriasis was not associated with in-hospital case-fatality in patients with ESRD (OR 1.02 (95%CI 0.78–1.33), p = 0.915). Conclusions: ESRD patients with the concomitant psoriasis diagnosis were hospitalized on average 5 years earlier than patients without psoriasis. A higher prevalence of severe life-shortening comorbidities including coronary artery disease and cancer was detected in ESRD patients with psoriasis despite their younger age. Our findings support the understanding of psoriasis as an autoimmune skin disease crossing the boundary between dermatology and internal medicine.

Impact of cardiac amyloidosis on outcomes of patients hospitalized with heart failure

BackgroundAmyloidosis is a multi-systemic disease potentially leading to failure of affected organs. We aimed to investigate prevalence and prognostic implications of cardiac amyloidosis of any etiology on outcomes of hospitalized patients with heart failure (HF) in Germany. MethodsWe analyzed data of the German nationwide inpatient sample (2005–2018) of patients hospitalized for HF (including myocarditis with HF and heart transplantation with HF). HF patients with amyloidosis (defined as cardiac amyloidosis [CA]) were compared with those HF patients without amyloidosis and impact of CA on outcomes was assessed. ResultsDuring this fourteen-year observational period 5,478,835 hospitalizations for HF were analyzed. Amyloidosis was coded in 5,407 HF patients (0.1%). CA prevalence was 1.87 hospitalizations per 100,000 German population. CA patients were younger (75.0[IQR 67.0–80.0]vs.79.0[72.0–85.0]years, p < 0.001), predominantly male (68.9%) and had a higher prevalence of cancer (14.8% vs. 3.6%, p < 0.001). Adverse in-hospital events including necessity of transfusions of blood constituents (7.1% vs. 5.4%, p < 0.001) and cardio-pulmonary resuscitation (CPR, 2.7% vs. 1.4%; p < 0.001) were more frequent in CA. CA was independently associated with acute kidney failure (OR 1.40 [95%CI 1.28–1.52], p < 0.001), CPR (OR 1.58 [95%CI 1.34–1.86], p < 0.001), intracerebral bleeding (OR 3.13 [95%CI 1.68–5.83], p < 0.001) and in-hospital mortality between the 5 and 8th decade of life, but in-hospital mortality was strongly influenced by cancer. ConclusionsCA was identified as an independent risk factor for complications and in-hospital mortality in HF patients, whereby it has to be mentioned that amyloidosis subtypes could not differentiated in the present study. Physicians should be aware of this issue concerning treatments and monitoring of CA-patients.

Obesity and Its Impact on Adverse In-Hospital Outcomes in Hospitalized Patients With COVID-19.

BackgroundAn increasing level of evidence suggests that obesity not only is a major risk factor for cardiovascular diseases (CVDs) but also has adverse outcomes during COVID-19 infection.MethodsWe used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19 diagnosis in Germany from January to December 2020 and stratified them for diagnosed obesity. Obesity was defined as body mass index ≥30 kg/m2 according to the WHO. The impact of obesity on in-hospital case fatality and adverse in-hospital events comprising major adverse cardiovascular and cerebrovascular events (MACCE), acute respiratory distress syndrome (ARDS), venous thromboembolism (VTE), and others was analyzed.ResultsWe analyzed data of 176,137 hospitalizations of patients with confirmed COVID-19 infection; among them, 9,383 (5.3%) had an additional obesity diagnosis. Although COVID-19 patients without obesity were older (72.0 [interquartile range (IQR) 56.0/82.0] vs. 66.0 [54.0/76.0] years, p < 0.001), the CVD profile was less favorable in obese COVID-19 patients (Charlson comorbidity index 4.44 ± 3.01 vs. 4.08 ± 2.92, p < 0.001). Obesity was independently associated with increased in-hospital case fatality (OR 1.203 [95% CI 1.131–1.279], p < 0.001) and MACCE (OR 1.168 [95% CI 1.101–1.239], p < 0.001), ARDS (OR 2.605 [95% CI 2.449–2.772], p < 0.001), and VTE (OR 1.780 [95% CI 1.605–1.973], p < 0.001) and also associated with increased necessity of treatment on intensive care unit (OR 2.201 [95% CI 2.097–2.310], p < 0.001), mechanical ventilation (OR 2.277 [95% CI 2.140–2.422], p < 0.001), and extracorporeal membrane oxygenation (OR 3.485 [95% CI 3.023–4.017], p < 0.001).ConclusionsObesity independently affected case fatality, MACCE, ARDS development, VTE, and other adverse in-hospital events in patients with COVID-19 infection. Obesity should be taken into account regarding COVID-19 prevention strategies, risk stratification, and adequate healthcare planning. Maintaining a healthy weight is important not only to prevent cardiometabolic diseases but also for better individual outcomes during COVID-19 infection.