Healthcare Cost And Utilization Project Research Articles

HAPPS: A Hidden Attribute and Privilege-Protection Data-Sharing Scheme With Verifiability

Data is a key asset in our interconnected and smart city. Especially, in the context of healthcare, healthcare data can facilitate remote diagnosis and medical research. Because of the potentially sensitive nature of healthcare data, privacy is a key consideration for both individuals and organizations. We can broadly categorize privacy considerations into data privacy, attribute privacy, and privilege policy privacy. To support one or more notions of privacy, the potential of solutions, such as fine-grained access control [e.g., those based on attribute-based encryption (ABE)] and blockchain in realizing data sharing has been explored. However, these approaches generally only facilitate access control of data and the traceability of the sharing process, and do not protect the attribute and privilege policy privacy of users. Therefore, in this article, we implement HAPPS, a hidden attribute and privilege-protection data-sharing scheme with verifiability. The three key building blocks of HAPPS are zero-knowledge proof, blockchain, and distributed ABE (DABE). Specifically, in our approach, we propose a new data access control strategy (i.e., attribute-hidden zero-knowledge proof—at-ZKP) to hide user identity and attributes during the authorization process. Our scheme is embedded in the blockchain and built into the decentralized sharing platform to prevent central verifier counterfeiting and support auditing. To demonstrate utility, we prove that HAPPS ensures data, attribute, and privilege policy privacy. Findings of our evaluations implemented on Ethereum and using the data set from the healthcare cost and utilization project (HCUP), we demonstrate that our scheme can share sensitive healthcare records belonging to minors (e.g., children) without the at-ZKP incurring unrealistic cost.

973. Clinical Outcomes and Resource Utilization in Children Who Develop Acute Kidney Injury Following Vancomycin Use for Treatment of MRSA Bacteremia and Acute Hematogenous Osteomyelitis

Abstract Background Children with acute hematogenous osteomyelitis (AHO) and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia are often treated with vancomycin (vanc) with risk of nephrotoxicity. This study evaluates resources used, and outcomes, of children with or without acute kidney injury (AKI) when vanc is used in this setting. Methods Children with AHO and MRSA bacteremia treated with vanc from 2009 to 2019 were retrospectively studied. AKI was assessed by chart review, for clinical diagnosis and by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Cohorts of children with or without KDIGO AKI were compared for differences of illness severity, treatment, resource utilization, and outcomes. Multivariate logistic regression analysis was accomplished to identify factors associated with risk for AKI. Cost analysis was performed using Pediatric Health Information System (PHIS) and Healthcare Cost and Utilization Project (HCUP) databases. Results Among 631 children with AHO, 85 children with MRSA bacteremia were treated with vanc for a sufficient duration to allow trough measurements. Of these, 14 (16.5%) had chart-diagnosed AKI, whereas 24 (28.2%) children met KDIGO criteria. Children with AKI had more febrile days and higher rates of thrombosis. They had longer duration of vanc treatment (8 vs 5 d) and higher troughs (27.8 vs 17.5 mg/L). The AKI group had more blood cultures, vanc troughs, creatinine levels, and longer length of stay (LOS; 19.9 vs 11.1 days). Multivariate analysis revealed that maximum vanc trough level (odds ratio 1.05) with a cutoff of 21.7 mg/L was a significant predictor of AKI. PHIS data of 3,133 children with AHO treated with vanc identified 75 (2.4%) with AKI who had significantly longer LOS (13 vs 7 d) and higher billed charges ($117K vs $51K) than children without AKI. HCUP data of 13,223 children with AHO identified 384 (2.9%) with AKI who had longer LOS (27 vs 6 d) and higher billed charges ($317K vs $37K) than those without. Conclusion Clinical diagnosis of AKI (16.5%) grossly underestimated the KDIGO occurrence (28.2%) in our population. This study showed vanc associated AKI results in significant increases in resource utilization and healthcare costs. A high vanc trough >21.7 mg/dL is a significant contributing factor to AKI. Disclosures All Authors: No reported disclosures.

Cost of Pediatric Trauma: A Comparison of Non-Accidental and Accidental Trauma in Pediatric Patients

BackgroundNonaccidental trauma (NAT) affects >100,000 children in the United States every year and is associated with significant mortality and morbidity. Little is known about the financial burden of NAT, particularly in comparison to accidental trauma (AT). We sought to compare hospital charges and outcomes between children presenting with NAT and AT. MethodsPediatric (<16 y) trauma hospitalizations from 2006 to 2018 were identified using the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and Kid’s Inpatient Sample (KID) databases. Hospitalizations were identified as NAT or AT based on ICD codes. Discharge weights were used to obtain national estimates and standardize them across the different sampling structures. Outcomes (hospital charges, length of stay (LOS), and mortality) were compared, and multivariate regression analyses were used to assess independent predictors of hospital charges and mortality. ResultsFifty-eight Thousand Two Hundred Seventy-five pediatric hospitalizations were included with 17,954 (0.3%) categorized as NAT. Children with NAT were younger, more female, less likely to identify as White, and more under public insurance than those with AT. Hospital charges were significantly higher in patients with NAT ($27,100 versus $19,900, P < 0.0001). Mortality (4.9% versus 0.0%, P < 0.0001) and LOS (3.2 d versus 1.5 d, P < 0.0001) were significantly higher among patients with NAT. Multivariable regression analyses identified NAT as a predictor of higher hospital charges, mortality, and LOS. ConclusionsNonaccidental trauma in pediatric patients is associated with significantly higher hospital charges, mortality, and LOS than accidental trauma. Ongoing research focused on the relative impact of known risk factors and resource utilization is needed.

Expanding the Use of Endoscopic Retrograde Cholangiopancreatography in Pediatrics: A National Database Analysis of Demographics and Complication Rates.

This study aimed to aid in risk assessment of pediatric endoscopic retrograde cholangiopancreatography (ERCP) candidates by utilizing a national pediatric database with a large sample to assess how patient characteristics may affect ERCP complication rates. The Kids' Inpatient Database (KID) is a sample of pediatric discharges in states participating in the Healthcare Cost and Utilization Project (HCUP). This database provides demographic information, hospitalization duration, and outcome information for hospitalizations during which an ERCP occurred. International Classification of Diseases (ICD) codes were used to determine the hospitalization indication. ERCP complication rate was ascertained via ICD codes. All statistical analyses were performed using SAS 9.4. Complications were seen in 5.4% of hospitalizations with mortality observed in less than 0.2%. This analysis captured a large Hispanic population, specifically in the South and West regions. Gallbladder calculus and cholecystitis were more likely to occur in females. A higher percentage of patients in the age 10 - 17 group were female (72.2% vs. 52.7%, P < 0.01) and Hispanic (33.4% vs. 22.7%, P < 0.01) compared to the age 0 - 9 group. Age 0 - 5 and male gender were associated with lower routine home discharge rates and longer lengths of stay. Complications occurred at a higher rate in ages 0 - 5, though the difference was not statistically significant. ERCP is a safe procedure for pediatric patients with low complication rates and rare mortality. We found statistically significant differences in the procedure indications between pediatric age groups, races, and genders. Age ≤ 5 years and male gender were associated with more complicated healthcare courses.

Social vulnerability index and firearms: How neighborhood health disparities affect trauma outcomes

Firearm injuries’ association with individual-level socioeconomic risk is well described. Trauma research has suggested that neighborhood level risk factors may be associated with differences in firearm injury outcome. We analyzed the relationship between hospital length of stay (LOS), mortality and neighborhood level social markers from the Center for Disease Control (CDC) Social Vulnerability Index (SVI) after firearm injury. We used the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) in 2016 to identify firearm injuries using ICD-10 E-codes. Patient locations were identified at the census tract level. The 2016 CDC SVI was used to evaluate neighborhood level social vulnerability. Logistic and linear multivariable regression were used to evaluate the association between SVI percentile rank, mortality, and LOS. We identified 9,764 cases of firearm injury in our database; 88.2% of individuals were male, and the average age was 33.8 years. Assault was the most common intent, accounting for 4682 (48.0%) of all admissions. Overall, SVI was correlated with the risk of firearm injury, but not associated with either outcome of length of stay or risk of death. While there is significant disparity between SVI and risk of firearm injury, once admitted to the hospital outcomes are similar between low and high-vulnerable populations. To reduce disparities in risk, funding and effort should focus on primary prevention.

Hospital Characteristics and Other Factors Associated with the Risk of Postpartum Hemorrhage in the United States.

Background: Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality in the United States. It occurs when blood loss exceeds 1000mL regardless of the delivery route. Careful assessment of various causes and risk factors of PPH is essential to reduce and prevent further complications, avoid maternal morbidity and mortality, and better manage PPH. This study aimed to examine the associations of hospital characteristics and regions of hospital locations across the United States with PPH risk, as the outcomes of such an assessment may contribute to practice-relevant scientific evidence to improve policies and protocols regarding effective PPH management. Methods: This retrospective study used the 2018 National Inpatient Sample database from the Healthcare Cost and Utilization Project (HCUP) to examine the associations of PPH risk with characteristics and regions of hospital lections. Results: After controlling for clinical risk factors, the results showed that hospitals owned by private investors had significant associations with decreased risk of PPH. Conversely, large bed size, urban teaching status, and West and Midwest location were associated with an increased risk of PPH. Conclusion: Additional research is needed to determine whether these variations across regions and hospital characteristics are due to differences in obstetric practice and management.

Impact of the Affordable Care Act on Disparities in Access to and Outcomes After Coronary Artery Bypass Grafting

ObjectivesThe aim of this study was to examine the effect of implementation of the Affordable Care Act’s Medicaid expansion on access to and outcomes after coronary artery bypass grafting (CABG) surgery.MethodsRetrospective observational study utilizing the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2011 to 2016. The southern region of the USA was used as a control and the western region as the implementation group. Univariate regression models and interrupted time series models were created to evaluate and assess the impact of the Affordable Care Act’s Medicaid expansion on mortality after CABG with respect to patient race.ResultsFrom 2011 to 2016, a total of 117,819 isolated CABG operations were identified in the specified regions using the HCUP NIS. Of these, 89,918 were performed in the southern region, and the remainder were performed in the western region. The proportion of African American patients with Medicaid increased significantly in the western region after the ACA Medicaid expansion, from 13.1 to 17.6%, p = 0.034. There was no significant increase seen in the number of African American patients with Medicaid in the southern region. We found that overall, Black patients had higher mortality after CABG as compared to white patients (OR 1.15, p = 0.02); however, when broken down by region we found higher mortality among African American patients in the southern region only, with no statistically significant difference in mortality between white and Black patients in the western region.ConclusionsImplementation of the Affordable Care Act increased access to Medicaid among Black Americans but did not necessarily decrease the disparity in access to CABG or mortality after CABG between Black and white patients. When it comes to racial disparities in mortality after CABG, there are significant regional and geographic variations which have not been previously described. This finding has important implications for the development of policy and other strategies that aim to reduce these disparities.

Prevalence and Risk Factors for Bleeding in Individuals with Hereditary Hemorrhagic Telangiectasia: A National Inpatient Sample Study

Background: Hereditary hemorrhagic telangiectasia (HHT) is the second most common hereditary bleeding disorder worldwide. Patients with HHT develop vascular anomalies in multiple organs that cause complications such as bleeding, thrombosis, anemia and high-output heart failure, resulting in poor quality of life. Few studies define the prevalence, risk factors, or screening tools for bleeding in HHT. Methods: We conducted a cross-sectional study of HHT patient discharges in the National Inpatient Sample (NIS) database from 2016-2018. Types of bleeding and other medical conditions were identified using ICD-10 codes. Analysis included NIS-provided discharge-level weights to reflect national estimates. NIS is the largest publicly available inpatient database in the U.S. developed by Healthcare Cost and Utilization Project (HCUP), containing a 20% stratified sample of U.S. hospital discharges. Categorical and continuous variables were assessed for association with HHT and bleeding status by Rao-Scott Chi-Square and weighted simple linear regression, respectively. Weighted multivariable logistic regression was performed to determine bleeding risk factors in HHT patients. Variables included gender, race, hypertension (HTN), chronic obstructive pulmonary disease (COPD), liver disease and cirrhosis, peptic ulcer disease (PUD), portal HTN, peripheral vascular disease (PVD), malignancy, hepatitis C (HCV), portal vein thrombosis (PVT) and Charlson Comorbidity Index (CCI). Results: Among 21,393,912 adult discharges, a total of 2591 discharges with HHT (0.012%) were identified. Compared with HHT without bleeding (HHT-NB), HHT discharges with bleeding (HHT-B) were more likely to be African American (15.8% vs 12.6%, p=0.046), male (44.4% vs 39.4%, p=0.03), have HTN (56.9% vs 51.0%, p=0.01); liver disease (21.6% vs 12%), cirrhosis (9.8% vs 5.4%), PUD (8.7% vs 1.0%), portal HTN (7.1% vs 3.0%), HCV (3.3% vs 1.3%), PVT (1.5% vs 0.3%), each p<0.001; PVD (6.9% vs 4.8%, p=0.03), and higher morbidity (CCI) (mean ± sd: 2.3 ± 0.09 vs 2.1 ± 0.05, p=0.03), while malignancy (3.9% vs 6.8%, p=0.008) was less common. Additionally, congestive heart failure (CHF) (26.1% vs 18.0%), gastroesophageal reflux disease (GERD) (25.5% vs 19.8%), liver disease (21.6% vs 12.3%), cirrhosis (9.8% vs 3.5%), portal HTN (7.1% vs 3.9%) and HCV (3.3% vs 1.3%), each p<0.001, were each more common in HHT-B than in non-HHT with bleeding (non-HHT-B). GI bleeding in HHT was as likely to occur in the upper GI tract as in non-HHT discharges (35.3% vs 36.7%, p=0.47), but significantly less likely in the lower GI tract (19.5% vs 29.8%, p<0.001). The most common type of bleeding in HHT were AV malformation (AVM) (32.1% vs 1.3%), epistaxis (17.7% vs 0.6%), and telangiectasia (2.3% vs 0.2%), each p<0.001, compared to non-HHT. Surgical/procedural bleeding (0.8% vs 4.2%), postpartum hemorrhage (PPH) (0.3% vs 6.5%), heavy menstrual bleed (HMB) (0.9% vs 5.9%), and malignancy (3.9% vs 10%) were less common in HHT vs non-HHT, each p<0.001, but iron deficiency anemia (IDA) was more common, 15.5% vs 7.5%, p<0.001, despite lower use of aspirin (4.7% vs 13.2%) or anticoagulants (5.1% vs 10.5%), each p<0.001, while mean length of stay (5.6 days vs 6.1 days, p=0.04) and inpatient mortality (1.8% vs 3.6%, p=0.01) were lower in the HHT group. In multivariable logistic regression, correlates of bleeding in HHT included PUD, adjusted odds ratio (AOR) 8.77 [95%CI 5.07 - 15.2]; PVT, AOR 3.81 [1.49 - 9.79]; and HCV, AOR 2.19 [1.17 - 4.08], while COPD, AOR 0.77 [0.61 - 0.98]; and malignancy, AOR 0.58 [0.36 - 0.94] were protective. Factors most commonly associated with HHT-B included CHF, AOR 2.57 [2.00 - 3.30]; and IDA, AOR 2.24 [1.82 - 2.77] compared to non-HHT-B. Conclusion: Among those with HHT, those with bleeding were more likely to be male, African American, and have HTN, PUD, and HCV than those without bleeding. GI tract AVM and angiodysplasia were the most common cause of bleeding in HHT. IDA was more common in HHT, but surgical and gynecological bleeding such as PPH and HMB were significantly less common compared to non-HHT. The presence of GI bleeding associated with AVM or angiodysplasia should raise the possibility of HHT. IDA was equally common in HHT with and without bleeding (15.5%) suggesting either lack of testing, poor response to therapy, or ongoing losses with unrecognized bleeding.

Pediatric Age at Hematopoietic Stem Cell Transplant: Associations with Non-Malignant Genetic Disease and Race

Introduction: Increasingly, hematopoietic stem cell transplant (HSCT) is used in pediatrics to treat both malignant and nonmalignant conditions. Many of the nonmalignant disorders for which HSCT is curative are genetic, and it has long been recognized that the diagnostic odyssey for patients with genetic disorders is frequently quite long. Notably, the diagnostic odyssey is longer for non-white patients with genetic diseases than for white patients with genetic diseases. We hypothesized that this disparity would also manifest as older age at time of HSCT, which could be associated with greater co-morbidities and worse outcomes. While previous studies have analyzed the association between race and pediatric HSCT access and survival, (PMID:32497418; 35071585; 34900869)we sought to determine if the diagnostic odyssey is longer for racial minorities compared to Caucasians. Methods: To test this hypothesis, we utilized the 2019 version of the Kids’ Inpatient Database (KID), developed by the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality (AHRQ). The HSCT sample was identified using ICD-10-PCS Procedure Codes for transfusion of hematopoietic/cord blood stem cells: Allogenic: 30243X3, 30243Y3, 30243X4, 30233X4, 30243Y2; Autologous: 30243Y0. A variable for pediatric genetic disease (PGD) was generated using 348 ICD-10-CM diagnostic codes corresponding to 283 pediatric genetic diseases for which the carrier frequency is greater than 1 in 500 in the general population or in an at-risk subpopulation (e.g., sickle cell anemia in AA). We controlled for malignant disease leading to HSCT using ICD-10-CM diagnostic codes to identify lymphomas, leukemias, myelodysplastic syndrome, myeloproliferative neoplasms, neuroblastomas, and brain tumors. Multiple linear regression was used to test if age of HSCT procedure was significantly associated with race, known non-malignant PGD, malignant disease, payer status, and location (rural vs. urban). Results: We identified 1,178 pediatric aged patients (age 20 and younger) who received HSCT in 2019 (Allogenic N=618; autologous N=560). The clinical characteristics of these patients are described in Table 1. The average age for Caucasian pediatric patients treated with HSCT is 6.8 years (82 months). Comparing PGD vs. all other diagnoses related to HSCT, patients with known PGD are transplanted on average 1.9 years (22 months) earlier than matched controls (P<0.001). This difference persists after controlling for race, disease severity, transplant type, Medicaid status, and rural health system location. African American and Asian pediatric patients are treated with HSCT on average 1.6 years (18 months) older than matched Caucasian controls (P=0.003 and 0.032, respectively). The effect of race persists even after controlling for thalassemias and sickle cell disease, associated with non-European ancestry. Conclusions: Age at transplant may be a useful surrogate for ongoing health disparities and to inform real-world research. African American and Asian ancestries are associated with HSCT at an older age, suggesting a prolonged diagnostic or therapeutic odyssey. This effect persists after controlling for factors such as non-malignant and malignant conditions, payer status, rural location, and genetic diseases that are over-represented in racial groups. More work is required to determine if this delay in treatment is due to differences in the spectrum of genetic diseases treated by HSCT in children of different ancestries, and if these delays in therapy may be associated with increased comorbidities and worse HSCT outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

National Burden of Encapsulated Bacterial Infections in Sickle Cell Disease

Introduction: Patients with sickle cell disease (SCD) are at much higher risk for infections from encapsulated organisms, particularly Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus), and Hemophilus influenzae. Vaccinations and prophylactic penicillin (for pneumococcus) have declined but not eliminated their incidence. We aim to study the SCD admissions with infections from above mentioned encapsulated organisms. Methods: We performed a retrospective analysis using the National Inpatient Sample (NIS) database from 2016 to 2019 to identify SCD hospitalizations with either S. pneumoniae, N. meningitidis, or H. influenzae infections using appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD 10-CM) codes. SCD included HbSS (D57.0x), HbSC (D57.2x) and others (D57.1, D57.4x and D57.8x). Infections from S. pneumoniae and H. influenzae included sepsis (A40.3, A41.3), pneumonia (J13, J14), meningitis (G00.1, G00.0), and others (M00.1x, B95.3, A49.2, B96.3, and J20.1). N. meningitidis infections were identified by ICD-10-CM code A39.x. Admissions were divided into pediatric (<18 years) and adult (≥18 years) age groups and descriptive analysis was performed to compare demographics, hospital characteristics, and comorbid conditions/complications. We also calculated the annual hospitalization rate for encapsulated organisms per 10,000 SCD admissions. The methodology provided by the HCUP (Healthcare Cost and Utilization Project) was utilized, and weights were applied to produce national estimates. Results: Out of 533,175 SCD admissions from 2016-2019, 830 (0.16%) had an infection from S. pneumoniae or H. influenzae. There were no admissions with N. meningitidis during our study period. The annual hospitalization rate for encapsulated bacterial infection per 10,000 SCD admissions ranged from 15.6/year to 40.6/year for the pediatric population and 11/year to 15.2/year among adults (Figure 1). Overall rate was 30 per 10,000 SCD admissions in pediatric population and 12 per 10,000 in adults (p <0.001). Among S. pneumoniae infections, hospitalizations were highest for children ≤5 years at 64 per 10,000 SCD admissions, followed by 14 per 10,000 in children aged >5 & <18 years and lowest in adults (≥18 years) at 12 per 10,000 (p <0.001). Among 695 SCD admissions with S. pneumoniae, 325 (46.8%) were HbSS, and 65 (9.4%) had HbSC disease. Furthermore, 260 (37.4%) were <18 years and 435 (62.6%) were ≥18 years. The median age for children was 5 (2-10) years and 34 (27-47) for adults (p <0.001). Most admissions were males (56.1%), without significant comorbidities (Charlson comorbidity index 0 in 59.7%) and belonged to lowest income communities (47.8%). More than a quarter of adults (26.4%) had tobacco use disorder, and 8.1% had HIV/AIDS. Incidence of acute respiratory failure and acute kidney failure was higher in adults than in children (25.3% vs. 1.9%; p <0.001 and 29.9% vs. 3.9%; p <0.001 respectively). The median length of stay was 6 (4-11) days for adults and 4 (3-7) days for <18-year-olds (p <0.001). There were 26.4% adults compared to 9.6% children with a length of stay >10 days (p 0.02). Median hospital charges and costs were also higher for adults compared to children. Whereas there were no pediatric discharges requiring home health care, 17.4% of adults had home health care arranged (p 0.01). All-cause-in-hospital mortality was 1.4%. Out of 145 H. influenzae admissions, 40 (27.6%) were <18 years, and 105 (72.4%) were ≥18 years. Like S. pneumoniae, the majority of SCD admissions with H. influenzae admissions were males (65.5%), belonged to the lowest income communities (51.7%), admitted to large (48.3%), teaching hospitals (89.7%), and had no significant comorbidities (Charlson comorbidity index 0 in 55.2%). Around 24.1% stayed in the hospital for >10 days, and 20.7% required invasive mechanical ventilation. The median length of stay was 7 (5-10) days, and all-cause-in-hospital mortality was 3.5% (Table 1). Conclusion: Despite vaccinations and prophylactic penicillin, the burden of encapsulated bacterial infections in pediatric SCD hospitalizations remains disproportionately higher than in adults. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 10093: Association Between B-Thalassemia and Atrial Fibrillation: Insights From the United States National Inpatient Sample

Introduction: β-thalassemia (BT) disease requires a lifelong blood transfusion. Despite improved prognosis with transfusion and chelation therapy, the iron overload can predispose to atrial fibrillation (AF). We sought to study the impact of AF on BT patients through large database analysis. Methods: The study used the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) for 2016-2019. Adult BT admissions were included. BT admissions were identified using ICD-10 code (D56.1). Admissions were stratified according to AF presence. A series of multivariate logistic regression was performed to evaluate the impact of atrial fibrillation on BT and to account for potential confounders. Continuous variables were compared using Student t-test, and categorical variables were compared using ꭓ2 tests. Subgroup analysis according to sex was performed. Outcomes evaluated were in-hospital mortality and prolonged length of stay (LOS) ≥ 75th percentile. Results: A total of 17,150 admissions were included, of which 2,100 (12.2%) had an associated diagnosis of AF. Admissions with AF were older (72.1 vs 47.3, P&lt;0.001), white race (66% vs 41%), and more likely to have congestive heart failure (CHF), hypertension, valvular heart disease, and renal disease. BT was associated with higher AF prevalence than non-BT admissions across all age groups. AF was not associated with increased risk of in-hospital mortality in the general cohort nor increased LOS (adjusted odds ratio [aOR]: 1.36 [0.67-2.78], P=0.398, and 1.00 [0.78-1.29], P=0.997, respectively). In subgroup analysis, including only female admissions, AF was associated with increased in-hospital mortality (aOR: 2.73 [1.09-6.8], P=0.031) but not with prolonged LOS (P=0.218). Predictors of in-hospital mortality were age, CHF, and liver disease, while predictors of prolonged LOS were Diabetes Mellitus in addition to CHF and age. Conclusions: We reported significant findings. First, AF is more common in BT compared to the general population, irrespective of age. Second, AF was independently associated with increased mortality in BT females. Third, CHF, liver disease, diabetes, and increased age are poor outcome predictors.

Abstract 14352: Variations in Spontaneous Coronary Artery Dissection Diagnosis Based Upon Hospital Status

Background: Spontaneous coronary artery dissection (SCAD) contributes to a significant number of acute coronary syndrome (ACS) in middle-aged female. SCAD data are accumulating to understand its epidemiology, etiology, presentation, and diagnosis. Despite the rising incidence, there is limited data regarding the number of diagnosed cases based on hospital location. We hypothesized that more cases of SCAD are diagnosed at teaching urban hospitals than urban non-teaching or rural hospitals. Methods: In this retrospective study, the discharge data were extracted from the National Inpatient Sample (NIS), and Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality from 2010 to 2017. We used the 9th and the 10th revisions of International Classification Disease (ICD-9-CM code 414.12, ICD-10-CM Code I25. 42) for SCAD. SCAD cases per year (weighted to represent nation sample) were collected and stratified by hospital location (urban teaching, urban non-teaching, and rural). p - value was calculated by Cochran-Armitage test. A p -value of &lt;0.05 was considered significant and all p-values were two-sided. Results: We found a total of 490 patients with a primary diagnosis of SCAD. The numbers were weighted to present a national total of 2432 discharges. Demographic characteristics are shown in table-1. Year-year SCAD cases quantified by rural, urban teaching, urban non-teaching status are shown in table-1. Of these 2432 discharges, 72.34% were at the urban teaching hospitals, followed by 25.05% at urban non-teaching hospitals, and only 2.6% were at rural hospitals. This difference was statistically significant (p -value &lt;0.001). Conclusions: A higher number of SCAD cases at urban teaching hospitals may indicate the diagnosis bias due to better availability of expertise and advanced modalities to diagnose this entity at urban teaching hospitals.

Abstract 9912: Cardiac Events Among Amyotrophic Lateral Sclerosis Patients in the United States; a Fresh Perspective From the 2019 National Inpatient Sample

Introduction: Respiratory distress and complications are the leading causes of death among Amyotrophic Lateral Sclerosis (ALS) patients. However, several studies have reported multiple cardiovascular complications linked with heart rate and rhythm. We, therefore, aim to investigate cardiovascular involvement among ALS patients further. Methods: Data from the 2019 National Inpatient Sample from the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (AHRQ), and partners were analyzed to estimate the presence of multiple cardiovascular events in patients with a diagnosis of Amyotrophic Lateral Sclerosis in the United States via their respective ICD-10 codes. The risk of cardiopulmonary resuscitations and mortality rates were also estimated via multivariate regression models, accounting for different variables. Results: We identified 12,865 cases of ALS in the United States. Different cardiac arrhythmias were recorded, such as supraventricular tachycardia (2.1%), ventricular tachycardia (1.7%), ventricular fibrillation (0.2%), and paroxysmal atrial fibrillation (3.8%), and long QT syndrome (0.6%). Several cases of heart blocks were also observed as 0.4% had a first degree, 0.3% had a second degree, and 0.3% had third-degree atrioventricular blocks. 10.7% also had a diagnosis of heart failure, and 565 (4.4%) patients had an old myocardial infarct. Finally, we found 160 (1.2%) cases of cardiopulmonary resuscitation, which had a higher risk of occurring among diabetics (aOR 1.922, 95%CI 1.383-2.670, p&lt;0.01) and patients with hypertension (aOR 1.516, 95% CI 1.007-2.134, p=0.017), while it was less common among Females (aOR 0.527,95% CI 0.368-0.755, p&lt;0.01). The adjusted odds ratio of death in ALS patients with cardiopulmonary resuscitation was 14.910 (95% CI 9.760-22.78, p&lt;0.01). Conclusions: Several cardiac arrhythmias can be observed among ALS patients. Cardiopulmonary resuscitation has a poorer outcome, and physicians treating ALS patients should be advised to watch for early changes, which may help reduce the need for CPR.

Clinical outcomes and 30-day readmissions associated with high-output heart failure

BackgroundHigh-output heart failure (HOHF) is an underdiagnosed type of heart failure (HF) characterized by low systemic vascular resistance and high cardiac output. ObjectiveThis study sought to characterize the causes, mortality, and readmissions related to HOHF within the United States. MethodsData were collected from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) National Readmissions Database (NRD) from January 1, 2017, to November 30, 2019. We used the International Classification of Diseases, 10th revision (ICD-10), diagnostic codes to identify encounters with HOHF and heart failure with reduced ejection fraction (HFrEF). ResultsOf the total 5,080,985 encounters with HF, 3,897 hospitalizations (mean age 62.5 ± 17.9 years, 56.5% females) with HOHF and 5,077,088 hospitalizations with HFrEF were recorded. The most commonly associated putative etiologies of HOHF included pulmonary disease (19.8%), morbid obesity (9.9%), sepsis (9.6%), cirrhosis (8.9%), myelodysplastic syndrome (MDS) (7.9%), hyperthyroidism (5.5%), and sickle cell disease (3.3%). There was no significant difference in mortality rates [4.3% vs. 5.2%; odds ratio (OR) 0.9, 95% confidence interval (CI) 0.7–1.2] between HOHF and HFrEF. However, the 30-day readmission rate for HOHF was significantly lower than that for HFrEF (5.7% vs. 21.2%; OR 0.39, 95% CI 0.30–0.51). Cardiovascular (39.9%) followed by hematological (20.6%) complications accounted for the majority of 30-day readmissions in the HOHF group. ConclusionsHOHF is an infrequently reported cardiovascular complication associated with noncardiovascular disorders and is encountered in 0.07% of all encounters with HF. Although comparable in-hospital mortality between studied cohorts was observed, raising awareness and timely recognition of this entity are warranted.

Ten-Year Trends in Mortality with Symptomatic Gallstone Disease and Emergency Cholecystectomy in New Jersey

Introduction: The epidemiology of death from symptomatic gallstone disease (SGD) may offer insight into current shortcomings of surgical and non-surgical therapy for SGD. Our aim was to explore in New Jersey (NJ) secular trends in mortality with SGD overall and mortality after emergency cholecystectomy. Methods: National Center for Health Statistics Restricted Mortality Data and Healthcare Cost and Utilization Project (HCUP) State Inpatient Data were used to examine NJ trends in calendar years 2009 to 2018. Outcomes were any death with SGD and inpatient death after emergency cholecystectomy. Death count and calendar year data were fit using simple linear regression. Results: There were 1580 deaths overall with 644 (40.76%) of those deaths after emergency cholecystectomy. A +2.05% relative change in deaths overall compared with a -57.58% relative change in deaths after emergency cholecystectomy from 2009 to 2018. Deaths overall remained flat [slope estimate -0.90; 95% CI -4.30, 2.51] while a downward linear trend occurred for deaths after emergency cholecystectomy [slope estimate -5.19; 95% CI -7.84, -2.53]. Conclusion: While overall rate of death with SGD in NJ was flat over a decade, substantial decreases were observed in inpatient death after emergency cholecystectomy. This needs to be reproduced in other states. However, any population trends in incidence of emergency vs non-emergency surgery for SGD are largely unknown. Examining medical and procedural treatments of emergency and non-emergency disease in addition to surgery may help to prevent mortality due to SGD.

Effect of frailty on in-hospital outcomes after transcatheter mitral valve repair

Abstract Background Mitral regurgitation (MR) is a common valvular disorder associated with significant morbidity and mortality. Transcatheter mitral valve repair (TMVr) is a minimally invasive procedure indicated for the treatment of selected patients with moderate-severe or severe primary MR. Despite a lack of a universal definition, frailty has been associated with poor post-procedural outcomes. Albeit several trials have examined individual prognostic factors in this population, there is a paucity of data regarding the effect of frailty on in-hospital outcomes after TMVr. Purpose To further elucidate the association of frailty with in-hospital outcomes in patients undergoing TMVr. Methods The national inpatient sample (NIS) database, which is part of the Healthcare Cost and Utilization Project (HCUP), was queried from 2016 to 2019 to identify all who underwent TMVr. International classification of diseases, tenth revision clinical modification (ICD-10-CM) codes were used to divide patients into frail and non-frail study groups. Frailty was defined using Johns Hopkins Adjusted Clinical Groups diagnosis cluster for frailty. Multivariate linear and logistic regression analysis was performed to compare in-hospital mortality, hospital length of stay, non-home discharge, and iatrogenic cardiac complications among Frail and Non-Frail groups. Results A total of 30,660 patients who underwent TMVr were identified. The mean age was 76±11.6 years. Of those, 2,950 (9.6%) were identified as frail. The overall in-hospital mortality rate for the entire study population was 1.89%. Compared to non-frail patients, those identified as frail had greater odds of in-hospital mortality (AOR= 2.13, 95% CI 1.29–3.51, p&amp;lt;0.001) and non-home discharge (AOR= 4.34, 95% CI 3.54–5.32, p&amp;lt;0.001). However, there was no statistically significant difference in hospital length of stay and rates of iatrogenic cardiac complications. Conclusions Frailty models continue to be underutilized as a prognostic tool in clinical practice. After following HCUP guidelines, our analysis found that frailty is independently associated with increased in-hospital mortality and non-home discharge in patients undergoing TMVr. Therefore, we recommend that further efforts in incorporating frailty models in the pre-procedural assessment of patients undergoing TMVr should be sought along with a standardized predictive model for defining frailty. Funding Acknowledgement Type of funding sources: None.

Trends and outcomes of veno-arterial extracorporeal membrane oxygenation for acute myocardial infarction-cardiogenic shock

Abstract Background Mortality for acute myocardial infarction-cardiogenic shock (AMI-CS) remains high. Trends of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use and outcomes as a function of ECMO requirement are not well described. Purpose To identify the trends and outcomes of VA-ECMO use for AMI-CS in the United States. Methods We used the Nationwide Readmissions Database (NRD) and the Healthcare Cost and Utilization Project (HCUP) to obtain our cohort. We identified patients with AMI-CS requiring VA-ECMO using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD 10 CM) and procedure (ICD 10-PCS) codes. We excluded patients with missing data on in-hospital mortality. Results During the study period (2016–2019), 2,005,607 records with myocardial infarction (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) were identified (national estimate of 3,674,083 records), 127,939 records (6.4%) had concomitant CS (national estimate of 234,630 patients), and 3,469 records (national estimate of 6,365 records) (2.7%) received VA-ECMO for CS support. Impella and Intra-aortic balloon pump were used within the same admission in 34.5% and 38.1% of VA-ECMO cases, respectively. VA-ECMO use for AMI-CS significantly increased over the study period (from 2.3% in the first quarter of 2016 to 3.3% in the last quarter of 2019, p=0.001) (Figure 1). In unadjusted analysis, patients undergoing VA-ECMO for AMI-CS were more likely to be male, have hypertension, congestive heart failure, and coagulopathy, present with STEMI, and receive multivessel PCI. Other comorbid conditions including diabetes, atrial fibrillation, end-stage renal disease, and prior MI, CABG, and stroke were less common in the VA-ECMO cohort. Medicare patients were less likely to receive VA-ECMO (39.4% vs. 63.8%, p&amp;lt;0.001), whereas patients at large or teaching hospitals were more likely. Patients requiring VA-ECMO had higher in-hospital mortality, length of stay, and rates of complications (Table 1). Conclusion Utilization of VA-ECMO for AMI-CS is increasing, and in one out three patients, VA-ECMO is used in combination with other MCS devices. Patients with underlying medical comorbidities and Medicare are less likely to receive VA-ECMO. Critically ill patients requiring VA-ECMO for AMI-CS are more likely to present with STEMI and have high morbidity and mortality. Funding Acknowledgement Type of funding sources: None.

Trends in Procedures in the Neonatal Intensive Care Unit.

The aim of the study is to identify the rates and trends of various procedures performed on newborns. The Healthcare Cost and Utilization Project (HCUP) database for the years 2002 to 2015 was queried for the number of livebirths, and various procedures using International Classification of Diseases, Ninth Revision (ICD-9) codes. These were adjusted to the rate of livebirths in each particular year. A hypothetical high-volume hospital based on data from the last 5 years was used to estimate the frequency of each procedure. Over the study period, there was a decline in the rates of exchange transfusions and placement of arterial catheters. There was an increase in the rates of thoracentesis, abdominal paracentesis, placement of umbilical venous catheter (UVC) lines, and central lines with ultrasound or fluoroscopic guidance. No change was observed in the rates of unguided central lines, pericardiocentesis, bladder aspiration, intubations, and LP. Intubations were the most performed procedures. Placement of UVC, central venous lines (including PICCs), arterial catheters, and LP were relatively common, whereas others were rare such as pericardiocentesis and paracentesis. Some potentially lifesaving procedures are extremely rare or decreasing in incidence. There has also been an increase in utilization of fluoroscopic/ultrasound guidance for the placement of central venous catheters. · Advances in neonatal care have impacted the number of procedures performed in the NICU.. · It is unclear whether invasive procedures occur at rates sufficient for adequate training and maintenance of skills.. · Understanding the NICU procedural trends is important in designing simulation and competency-based medical education programs..

Diabetes associated with higher health care utilization and poor outcomes after COPD-related hospitalizations.

Readmissions after hospitalizations for acute exacerbation of chronic obstructive pulmonary disease (COPD) have a high socioeconomic burden. Comorbidities such as diabetes increase the risk for hospital readmissions, but the impact of diabetes on hospital outcomes remains unknown. The aim of this study was to evaluate the effect of complicated or uncomplicated diabetes on outcomes and health care costs related to admissions and readmissions in patients 35 years and older with an index admission for COPD. This was a retrospective longitudinal data analysis. We analyzed data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database. We analyzed the 2012-2015 HCUP Nationwide Readmissions Database and used multivariable weighted regression analyses to adjust for confounding factors. Individuals with any chronic pulmonary disease other than COPD were excluded. Of 1,728,931 patients hospitalized for COPD, 522,020 (30.2%) had a diagnosis of diabetes. Risk of all-cause 30-day readmission was higher among patients with complicated diabetes (adjusted odds ratio [OR], 1.15; 95% CI, 1.11-1.18) and uncomplicated diabetes (adjusted OR, 1.10; 95% CI, 1.08-1.12) compared with patients without diabetes. Diabetes was associated with longer length of stay, higher rates of hospital complications during index hospitalizations and 30-day readmissions, and a higher health care cost. Although diabetes was not associated with higher hospital mortality, routine hospital discharges were less common and the need for home health care upon discharge was higher among those with diabetes. Patients hospitalized for COPD and coexisting diabetes have worse clinical outcomes and higher 30-day readmissions compared with patients hospitalized for COPD without diabetes. Optimizing medical therapies and targeted interventions for both diseases is needed to alleviate disease burden to individuals and to society.

Minimally Invasive Surgery in the United States, 2022: Understanding Its Value Using New Datasets

IntroductionWhile minimally invasive surgery (MIS) has transformed the treatment landscape of surgical care, its utilization is not well understood. The newly released Nationwide Ambulatory Surgery Sample allows for more accurate estimates of MIS volume in the United States—in combination with inpatient datasets. Materials and methodsMultiple nationwide databases from the Healthcare Cost and Utilization Project (HCUP) were used: the Nationwide Ambulatory Surgery Sample and National Inpatient Sample. The volume of MIS and robotic procedures were calculated from 2016 to 2018. An online query system, HCUPNet, was queried for inpatient stays from 1993 to 2014. ResultsIn 2017, 9.8 million inpatient major operating room procedures were analyzed, of which 11.1% were MIS and 2.5% were robotic-assisted, compared with 9.6 million inpatient operating room procedures (11.2% MIS and 2.9% robotic-assisted) in 2018. There were 10.6, 10.6, and 10.7 million ambulatory procedures in 2016, 2017, and 2018, respectively. Ambulatory MIS procedures showed an increasing trend across years, representing 16.9%, 17.4%, and 18%, respectively. HCUPNet data revealed an increase in inpatient MIS cases from 529,811 (8.9%) in 1993 to 1,443,446 (20.7%) in 2014. ConclusionsThis study is the first to estimate national MIS volume across specialties in both inpatient and ambulatory hospital settings. We found a trend toward a higher proportion of MIS and robotic cases from 1997 to 2018. These data may help contribute to a more comprehensive understanding of MIS value within surgery and highlight limitations of current databases, especially when categorizing robotic cases on a national scale.