Healthcare Cost Utilization Project Research Articles

Sleep disorders and relative risk of suicidal ideation and suicide attempts in youth presenting to emergency departments

ObjectiveSleep problems predict suicide, which is a leading cause of death in adolescents and young adults, but the relative risk of suicidality in youth with sleep disorders has not been established in nationally representative samples. This study evaluated the relative risk of suicidal ideation and attempt in youth ages 6-24 who presented to United States emergency departments between 2015 and 2017. MethodsYouths’ diagnoses of sleep and psychiatric disorders, and emergency department encounters with suicide attempt and suicidal ideation, were extracted from the Health Care Cost Utilization Project’s Nationwide Emergency Department Sample (N = 65,230,478). Relative risk of suicidal ideation and suicide attempt were evaluated through logistic regression and predicted rate ratios after adjustment for history of self-harm and demographic characteristics. ResultsYouth with at least 1 sleep disorder had 3 times greater odds of an emergency department encounter involving suicidal ideation compared to those without a sleep disorder (aOR = 3.22, 95% CI: 2.61, 3.98). The predicted probability of suicidal ideation was 46.03% higher in youth with a mood disorder and a sleep disorder, and 47.04% higher in youth with a psychotic disorder and sleep disorder, compared to youth without a sleep disorder. Only 0.32% of youth presenting to emergency departments were diagnosed with a sleep disorder. ConclusionsSleep disorders are associated with increased risk for suicidal ideation in youth presenting to emergency departments. Sleep disorders are also underdiagnosed in youth presenting to emergency departments relative to their estimated prevalence in epidemiologic surveys. Research and public health campaigns to prevent suicide in youth should incorporate assessment and intervention for sleep disorders.

COVID-19 and Clostridioides difficile Coinfection Outcomes among Hospitalized Patients in the United States: An Insight from National Inpatient Database.

The incidence of Clostridioides difficile infection (CDI) has been increasing compared to pre-COVID-19 pandemic levels. The COVID-19 infection and CDI relationship can be affected by gut dysbiosis and poor antibiotic stewardship. As the COVID-19 pandemic transitions into an endemic stage, it has become increasingly important to further characterize how concurrent infection with both conditions can impact patient outcomes. We performed a retrospective cohort study utilizing the 2020 NIS Healthcare Cost Utilization Project (HCUP) database with a total of 1,659,040 patients, with 10,710 (0.6%) of those patients with concurrent CDI. We found that patients with concurrent COVID-19 and CDI had worse outcomes compared to patients without CDI including higher in-hospital mortality (23% vs. 13.4%, aOR: 1.3, 95% CI: 1.12-1.5, p = 0.01), rates of in-hospital complications such as ileus (2.7% vs. 0.8%, p < 0.001), septic shock (21.0% vs. 7.2%, aOR: 2.3, 95% CI: 2.1-2.6, p < 0.001), length of stay (15.1 days vs. 8 days, p < 0.001) and overall cost of hospitalization (USD 196,012 vs. USD 91,162, p < 0.001). Patients with concurrent COVID-19 and CDI had increased morbidity and mortality, and added significant preventable burden on the healthcare system. Optimizing hand hygiene and antibiotic stewardship during in-hospital admissions can help to reduce worse outcomes in this population, and more efforts should be directly made to reduce CDI in hospitalized patients with COVID-19 infection.

A review of the literature: How does prenatal opioid exposure impact placental health and fetal brain development?

In recent years, there has been a sixfold increase in the number of pregnant people with opioid use disorder (OUD). Rates of neonatal opioid withdrawal syndrome (NOWS), previously known as neonatal abstinence syndrome (NAS), have significantly increased in virtually every state and demographic group(HealthcareCostUtilizationProject,HCUP,2010). NOWS is a condition resulting from chronic exposure to either therapeutic opioid use (e.g., medication for OUD, chronic pain conditions) or nonprescribed opioid use. To date, there is no known prenatal treatment to help decrease the risk of infants developing NOWS and subsequent neurodevelopmental outcomes. Given the increasing support for how placental signaling, or placental programming, may play a role in downstream pathology, prospective research investigating how the placenta is affected by chronic opioid exposure morphologically, histologically, and at the cellular level may open up potential treatment opportunities in this field. In this review, we discuss literature exploring the physiological roles of nitric oxide and dopamine not only in the vascular development of the placenta, but also in fetal cerebral blood flow, neurogenesis, neuronal differentiation, and neuronal activity. We also discuss histological preclinical studies that suggest chronic opioid exposure to induce some combination of placental dysfunction and hypoxia in a manner similar to other well-known placental pathologies, as denoted by the compensatory neovascularization and increased utilization of the placenta's supply of trophoblast cells, which play an essential role in placental angiogenesis. Overall, we found that the current literature, while limited, suggests chronic opioid exposure negatively impacts placental function and fetal brain development on a cellular and histopathological level. We conclude that it is worthwhile to consider the placenta as a therapeutic target with the ultimate goal of decreasing the incidence of NOWS and the long-term impacts of prenatal opioid exposure.

Foreign Body Aspiration Complicated by Pneumothorax in Children: HCUP-KID Perspective.

Children with airway foreign bodies (AFB) occasionally have pneumothorax complicating their course. We aimed to compare the clinical course of these children to those without this complication. Data was obtained from the 2016 Kids' Inpatient Database of Healthcare Cost Utilization Project. ICD-10 code of T17XXXX was used to locate records. They were grouped based on the presence of preoperative pneumothorax, postoperative pneumothorax, or none. Variables included demographics, AFB type, AFB location, length of stay (LOS), pneumothorax treatment modality, mortality, hospital setting, primary payor, and total charges. A total of 4165 children with AFB were identified, 57.8% male and 42.2% female. Of these 75 (1.8%) patients presented with preoperative pneumothorax, 29 (0.7%) with postoperative pneumothorax, and 4061 (97.5%) with no pneumothorax. The preoperative pneumothorax patients were older than the postoperative pneumothorax and unaffected AFB patients (mean age = 9.5 [95% CI 7.7-11.3] vs 8.2 [95% CI 5.4-11.1] vs 5.5 [95% CI 5.3-5.7]; P < .001). Preoperative pneumothorax patients incurred higher total charges than the other groups (mean US = $939K [95% Cl 673K-1,204K] vs $599K [95% Cl 377K-821K] vs $228K [95% Cl 211K-244K]; P < .001), had a longer LOS in days (mean = 37.7 [95% Cl 28.7-46.7] vs 31.6 [95% Cl 16.9-46.2] vs 15.8 [95% CI 15.0-16.7]; P < .001), and had a higher mortality rate (16% vs 0% vs 3.7%, P < .001). Pneumothorax can significantly impact a child's hospital course, and preoperative pneumothorax should alert clinicians to the potential for increased mortality risk.

Preventable Hospitalizations in Adults With Alzheimer's Disease and Related Dementias: United States, 2016–2018

Alzheimer's disease and related dementias (ADRD) are a significant public health burden. Preventing hospitalizations in adults with ADRD is a public health priority. Data from the 2016–2018 Healthcare Cost Utilization Project National Inpatient Sample, an all-payer representative sample of US hospitalizations, were used to describe potentially preventable hospitalizations in adults ≥45 years with ADRD using International Classification of Disease, Tenth Edition, Clinical Modification (ICD-10-CM) codes. Definitions for principal or any-listed ICD-10-CM codes from the Agency for Healthcare Research and Quality defined potentially preventable hospitalizations where admissions might have been avoided by appropriate outpatient primary care management. Of discharges in adults ≥45 years with a potentially preventable hospitalization diagnosis, 11.4% (N=389,155) had a diagnosis of ADRD listed in any position. Of those discharges with ADRD, a significantly higher proportion (82.6%) with diagnosis related to potentially preventable hospitalizations were aged ≥75 years compared to 78.9% without potentially preventable hospitalizations. Additionally, of those with ADRD and potentially preventable hospitalization diagnoses, a higher proportion died in the hospital (5.7%) compared to those without potentially preventable hospitalization diagnoses (3.4%). The most common potentially preventable hospitalization diagnoses among adults with ADRD were related to sepsis (34.0%), injuries (20.8%), urinary tract infections (14.2%), and heart failure (12.7%). Measures focusing on preventing injuries as well as identifying early signs and symptoms of potentially preventable hospitalizations like urinary tract infections and sepsis in adults with ADRD could reduce the number of preventable hospitalizations in this population.

Medicaid Expansion’s Impact on Emergency Department Use by State and Payer

ObjectivesThe Affordable Care Act’s Medicaid Expansion Program influences healthcare use by increasing insurance coverage. Of particular interest is how this will affect inefficient and expensive emergency department (ED) visits. We estimated the impact of the Medicaid expansion on ED use by states and payer (Medicaid, private insurance, and uninsured) 5 years after the implementation of the Medicaid expansion and illustrated the use of the generalized synthetic control method. MethodsIn this quasi-experiment study, we implemented the generalized synthetic control method to compare states with Medicaid expansion and states without Medicaid expansion. Data were from the Healthcare Cost Utilization Project Fast Stats, which cover >95% of all ED visits. We included states with complete data from 2010 to 2018. ResultsOverall, the Medicaid expansion increased Medicaid share of ED visits (average treatment effect on the treated [ATT] 11.39%; 95% confidence interval [CI] 8.76-14.02) and decreased private share of ED visits (ATT −5.80%; 95% CI −7.40 to −4.12) and uninsured share of ED visits (ATT −6.66%; 95% CI −9.78 to −3.55). ConclusionsMedicaid Expansion Program shifted ED payer mix to Medicaid ED visits from private insurance and uninsured ED visits for adults at age of 19 to 64 years, whereas its effect on total ED volume is mixed among states. States that experienced the largest increase in Medicaid enrollment seem to experience an increase in ED visits although such results did not reach statistical significance.

Gender based outcome of IABP implantation in patients with acute coronary syndrome and cardiogenic shock: a national inpatient sample database analysis

Abstract Background Intra-Aortic Balloon counter-pulsation is frequently used as a circulatory support device in patients requiring hemodynamic support - in cardiogenic shock and in patients at risk of hemodynamic decompensation during a high-risk coronary intervention. Impact of IABP in this patient population has been variable. Certain studies have shown a beneficial effect of IABP on selected populations having acute coronary syndrome with cardiogenic shock (1–3). Our objective was to compare the outcomes based on gender in the ACS population with cardiogenic shock and IABP placement. Methods We analyzed the National Inpatient Sample database from Oct-2015 to Dec-2017 released under Healthcare Cost utilization Project in the USA using Stata 16.0. The population was identified using respective ICD-10 codes. We excluded the population with sudden cardiac arrest, pulmonary embolism, and patients with anatomical post-MI complications. Multivariate logistic regression analysis was done to determine the difference in outcomes based on gender using clinically relevant variables. Later, propensity-matched cohort analysis was performed based on the regression variables. Results Of 36, 990 patients who met our inclusion criteria 25,670 (69%) were male and 11,320 (31%) were female. The average age for male and female populations was 66±11 and 69±12 years. Femnales were more likely to have higher Charlson co-morbidity index three or above. We found higher mortality in the female population [3,146 (27.79%)] compared to male [5,884 (22.92%)] in univariate analyses. Propensity-matched multivariate regression analysis showed no difference [OR: 1.06 (0.91–1.22) with P-value: 0.482] in mortality after adjusting for clinically relevant variables. Subgroup analysis in STEMI and NSTEMI populations did not show a difference. The average hospital stay was similar in both cohorts, with the male having a higher cost per stay. We found no difference in most of the complications included in our study except for higher coronary artery dissection [OR: 2.98 (1.73–5.13), P-value: &amp;lt;0.001] and lower rates of AKI [OR: 0.72 (0.63–0.83), P-value: &amp;lt;0.001], AKI requiring hemodialysis [OR: 0.74 (0.56–0.97), P-value:0.031] and ventricular tachycardia [OR: 0.73 (0.64–0.84), P-value: &amp;lt;0.001] in the female population. Conclusion The inpatient population of ACS with Cardiogenic shock and IABP insertion showed no significant difference in mortality between males and females which was valid for subgroup analysis of NSTEMI and STEMI groups. Complications such as coronary artery dissection were higher, whereas AKI, AKI requiring hemodialysis, and ventricular tachycardias, were lower in females than males. Funding Acknowledgement Type of funding sources: None.

The Impact of Inter‐ICU Transfer Timing on Clinical and Economic Outcomes

Research ObjectiveTo examine the impact of transfer timing on in‐hospital mortality, hospital length of stay (LOS), and cumulative charges on acute respiratory failure (ARF) patients.Study DesignWe conducted a retrospective, quasi‐experimental study utilizing Healthcare Cost Utilization Project databases (HCUP‐SID) in 5 states (FL, MD, MS, NY, WA) during 2015–2017. To control for potential selection bias, we propensity score matched patients (1:1) to model propensity for early transfer using a priori defined patient demographics, clinical, and hospital variables that influence the probability of inter‐ICU transfer. Doubly‐robust multivariable modeling was used to examine the impact of transfer timing on in‐hospital mortality, hospital length of stay (LOS), and cumulative charges.Population StudiedPatients with ICD‐10 codes for respiratory failure and mechanical ventilation who underwent an inter‐ICU transfer, grouping as early (≤ 2 days) and delayed transfers (3+ days).Principal Findings6718 patients with ARF underwent inter‐ICU transfer, 68% of whom (n = 4552) were transferred early (≤ 2 days). Propensity score matching yielded 3774 well‐matched patients for this study. Unadjusted outcomes were all lower in the early vs. delayed transfer cohort: in‐hospital mortality (24.4% vs. 36.1%; p &lt; 0.0001), length of stay (8 vs. 22 days; p &lt; 0.0001), and cumulative charges (118,686 vs. 308,977; p &lt; 0.0001). Through fully‐adjusted multivariable modeling, we found patients who were transferred early had 66% lower odds of in‐hospital mortality than those whose transfer was delayed (OR 0.34, 95% CI: 0.29–0.40). Additionally, the early transfer cohort had lower LOS [6.8 fewer days (10.8 vs. 17.6; p &lt; 0.001)], and lower cumulative charges [$94,471 less ($207,211 vs. $301,682; p &lt; 0.001)].ConclusionsOur study is the first to use a large, multi‐state sample to evaluate the practice of inter‐ICU transfers in ARF. This definition of early and delayed transfers is also distinct from past work, which has more commonly grouped all transfers together. The main finding of our study is that early transfers have a 66% decrease in mortality. These findings are vital in designing prospective studies evaluating evidence‐based transfer procedures, policies, and guidelines.Implications for Policy or PracticeAcute respiratory failure (ARF) leads to 2.5 million ICU admissions annually, resulting in over 30% mortality with an estimated cost of $27 billion. Current data estimates that 1 in 30 patients with ARF will undergo an inter‐ICU transfer, typically to receive a higher level of care. Although implications of inter‐ICU transfer are varied, there are currently no studies evaluating the impact of timing of transfer on outcomes. Our study suggests earlier ICU transfer may yield lower mortality rates, decreased LOS, and cumulative charges. The study however implies only associations and not causation which will need to be evaluated in future studies.Primary Funding SourceNational Institutes of Health.

Healthcare utilization and outcomes in HIV versus non-HIV patients with anal cancer: A nationwide analysis.

e15505 Background: Anal cancer (AC) is the most common HPV-associated cancer in men with HIV. Nearly one third of men with anal cancer have HIV with HPV accounting for 88% of cases. Studies have reported mixed outcomes in HIV-Anal Cancer (HIV-AC) compared to non-HIV-AC patients with most studies being small and retrospective. There were no clear explanations for the differences in the outcomes in both groups. We studied HIV-AC patients from a national database and compared the outcomes and healthcare utilization with non-HIV AC cohort. Methods: We identified all adult patients with AC, with and without HIV, between 2016-2018 from the Healthcare Cost Utilization Project (HCUP) National Inpatient Sample (NIS) database. The groups were compared for socio-demographic differences, inpatient mortality, length of stay (LOS) and total hospital charges (THC). Secondary outcomes studied were rate of acute kidney injury (AKI), tumor lysis syndrome (TLS), lower GI Bleed (LGIB), anemia, tumor lysis (TLS), sepsis, septic shock (SS), neutropenia and protein energy malnutrition (PEM). Statistics was performed using the t-test, univariate and multivariate logistic regression using Stata software. Results: A total of 1235 inpatient admissions with HIV-AC and 10,415 with non-HIV-AC were identified. HIV-AC patients were significantly younger (mean age 50.2 vs 63 years, p &lt; 0.0001) with few over 65 years (8% vs 44.2%, p &lt; 0.0001), more men (82.6% vs 30.8%, p &lt; 0.001), more likely African Americans (AA) (47.8% VS 11.2%, p &lt; 0.0001) and significantly more likely to be treated at a teaching hospital (90.7% vs 9.3%, p &lt; 0.0001) compared to non-HIV-AC cohort. HIV-AC patients had significantly lower odds of inpatient mortality (aOR= 0.26, CI = 0.093 – 0.705, p = 0.008) but higher LOS (7.4 vs 6.5 days, p = 0.02) and higher THC ($74,131 vs $60,864, p = 0.005). Rates of sepsis were higher in HIV-AC (OR = 2.11, CI = 1.465 - 3.028, p &lt; 0.0001) compared to non-HIV-AC, but odds of AKI, TLS, LGIB, SS, anemia, neutropenia and PEM were similar. Conclusions: HIV-AC patients are more likely to be younger, AA, men and have significantly lower inpatient mortality compared to non-HIV-AC, despite higher rates of sepsis. HIV-AC patients being younger and overwhelmingly (90%) treated at teaching hospitals may be contributing to the observed lower mortality. However, the HIV-AC cohort was also a high inpatient healthcare utilizer with significantly increased hospital charges amounting to over $16 million over 3 years. The reversal of sex incidence likely reflects the different exposure to HPV in HIV and non-HIV cohorts. Prospective studies are needed to further evaluate outcomes in HIV-AC patients and identify underlying contributors of higher utilization.

A nationwide analysis of inpatient outcomes and healthcare utilization in HIV versus non-HIV patients with esophageal cancer.

e16106 Background: Esophageal cancer (EC) is an aggressive malignancy with poor 5-year survival rates (19.9%). Due to effective Antiretroviral Therapy, mortality from HIV/AIDS has precipitously decreased leading to longer lifespan and increased risk of developing non-AIDS defining cancers. There is paucity of data regarding outcomes of Esophageal Cancers in patients with HIV (HIV-EC). We undertook this analysis to study the outcomes of HIV-EC with healthcare utilization compared to non-HIV-EC patients. Methods: The Healthcare Cost Utilization Project (HCUP) Nationwide Inpatient Sample was queried to identify patients with HIV and non-HIV-EC using ICD-10 codes. Groups were compared for demographic differences, inpatient mortality, length of stay (LOS) and hospital charges. Secondary outcomes studied included rates of septic shock (SS), Esophageal Obstruction (EO), Anemia, Pneumonia, Tracheoesophageal Fistula (TEF), Upper GI Bleed (UGIB), Acute Kidney Injury (AKI), protein energy malnutrition (PEM). Statistics were performed using the t-test, chi-square test and logistic regression. Results: A total of 330 inpatient admissions with HIV-EC and 117505 with non-HIV-EC were identified. Patients with HIV-EC were significantly younger (mean age 58.5 vs 66.9 years, p &lt; 0.001) with 83% under 65 years of age compared to 41% in non-HIV-EC group (p &lt; 0.001). Higher number of HIV-EC patients were African American (AA) (51.5% vs 10%, p &lt; 0.001) with similar gender ratio (19.7% vs 21.3% women), belonged to lowest income quartile zip codes (42% vs 27%, p = 0.01), more likely to be on Medicaid (36% vs 11%, p &lt; 0.001) and hailed from North East (NE) or Southern regions of the US (79% vs 56%, p = 0.003). The overall mortality rate was significantly higher in the HIV-EC group than non-HIV-EC (13.6% vs 8.8%, p = 0.001). The mean inpatient LOS (7.4 vs 6.98 days) and total hospital charges ($65,358 vs $80,620) were not significantly different between the two groups. Rates of PEM were higher in HIV-EC (61% vs 44%, p &lt; 0.01) but rates of sepsis, SS, UGIB, EO, TEF, Anemia, TLS, AKI were not significantly different than non-HIV-EC. There was no difference in rates of specific medical co-morbidities between groups, although HIV-EC had a significantly higher Charlson Comorbidity Index (p &lt; 0.001). Conclusions: Despite being significantly younger, HIV-EC patients have significantly higher mortality compared to non-HIV-EC. However, the inpatient LOS and total charges were not significantly different. HIV-EC were more likely to be AA on Medicaid and from low-income zip codes from the NE or South of the United States. Further studies are needed to study the role of early diagnosis, perhaps screening in younger patients with HIV to prevent mortality.

Healthcare utilization and outcomes in HIV versus non-HIV patients with hepatocellular cancer: A nationwide analysis.

e16189 Background: Hepatocellular Carcinoma (HCC) remains a leading cause of cancer related mortality and has a 5-year survival after diagnosis of under 20%. HIV-HCC patients are reported to present with advanced disease and shorter survival compared to non-HIV-HCC patients. HIV has not been known to have a direct causal relationship with HCC but chronic immunosuppression, direct effects of HIV virus on liver parenchyma and use of hepatotoxic antiretroviral medications are thought to contribute to the pathogenesis of HCC (Curr Opin HIV AIDS 2017;12:20-25). We studied differences in outcomes and healthcare utilization between HIV and non-HIV-HCC from a national database. Methods: Healthcare Cost Utilization Project (HCUP) National Inpatient Sample (NIS) database was queried to identify all HIV and non-HIV HCC admissions between 2016-2018. The groups were compared for socio-demographic differences, inpatient mortality, length of stay (LOS) and total hospital charges (THC). Secondary outcomes studied were rates of acute kidney injury (AKI), encephalopathy, anemia, upper GI Bleed (LGIB), tumor lysis (TLS), portal hypertension (PH), sepsis, septic shock (SS), neutropenia and protein energy malnutrition (PEM). Statistics were performed using the t-test, univariate and multivariate logistic regression. Results: A total of 845 HIV-HCC and 88,805 non-HIV-HCC inpatient admissions were identified. Compared to non-HIV-HCC, HIV-HCC patients were significantly younger (mean age 59.3 vs 64.7 years, p &lt; 0.0001) with fewer over 65 years old (21.9 % vs 47.4%, p &lt; 0.0001), more males (87.6% vs 74.3%, p &lt; 0.0002) and African American (AA) (44.8% VS 15.9%, p &lt; 0.0001). HIV-HCC cohort were more likely to be treated at a teaching hospital (89% vs 81%, p &lt; 0.035) and had higher comorbidity burden as defined by a high Charlson comorbidity index (p &lt; 0.01) compared to non-HIV-HCC. Odds of adjusted inpatient mortality (aOR= 0.47, CI = 0.27–0.82, p = 0.007) was significantly lower in HIV-HCC with similar LOS (6.5 vs 6.1 days, p = NS) and THC ($85,930 vs $84,592, p = NS) compared to non-HIV-HCC. While rates of neutropenia (2.96% vs 0.62%, p &lt; 0.001) and PEM (26.0% vs 16.3%, p = 0.01) were higher in HIV-HCC, rates of other secondary outcomes were similar compared to non-HIV cohort. Conclusions: HIV-HCC patients are younger, AA, and men with significantly lower inpatient mortality and similar healthcare utilization compared to non-HIV-HCC, despite higher rates of PEM and neutropenia, possibly reflecting advancements in HIV-HCC treatment, and contributed to by younger age and treatment at teaching hospitals. Further studies are needed to evaluate and assess the effect of co-infection with hepatitis on HIV-HCC outcomes which was not evaluated in present study and investigate interventions aimed to reduce complications like PEM and neutropenia to further improve outcomes.

Trends and Inpatient Outcomes of Primary Heart Failure Hospitalizations with a Concurrent Diagnosis of Acute Exacerbation of Chronic Obstructive Pulmonary Disease (from The National Inpatient Sample Database from 2004 to 2014)

Heart failure (HF) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are considered significant causes of morbidity and mortality worldwide. Concurrent presentation of HF with AECOPD can pose a diagnostic challenge due to an overlap in symptomatology. We queried the National Inpatient Sample (NIS) database to assess outcomes of HF hospitalizations with a secondary diagnosis of AECOPD. We performed a retrospective analysis of discharge data from the Healthcare Cost Utilization Project NIS between January 1, 2004, and December 31, 2014, with a primary diagnosis of HF with and without a secondary diagnosis of AECOPD. Data was abstracted from the NIS using International Classification of Disease 9 codes. Primary outcomes included mortality, length of stay, and inflation-adjusted cost of stay. During 2004-2014, a total of (n = 10,392,628) HF hospitalizations were identified without a secondary diagnosis of AECOPD while (n = 989,713) HF hospitalizations were identified with a secondary diagnosis of AECOPD. We identified higher mortality (3.25% vs 3.56%, p <0.001), length of stay (5.2 vs 6.1 days, p <0.001) and inflation-adjusted cost of stay (12,562 vs 13,072 USD, p <0.001) in HF hospitalizations with AECOPD when compared to HF without AECOPD from 2004 to 2014. We presented AECOPD as an independent predictor of mortality in patients admitted for HF. In conclusion, further interdisciplinary collaboration between pulmonologists and cardiologists is needed for the identification and stratification of patients who present with concurrent HF and COPD for better outcomes.

Hospitalizations in Adults With Alzheimer’s Disease and Related Dementia—United States, 2016–2017

Alzheimer’s disease and related dementias (ADRD) are a significant public health burden. Collectively, ADRD have been called the most expensive chronic conditions in the United States due to outsized health care utilization. Data from the 2016 and 2017 Healthcare Cost Utilization Project National Inpatient Sample, an all-payer representative sample of US hospitalizations, were used to describe hospitalizations in adults ≥65 years with ADRD. Chronic conditions were defined using International Classification of Disease, Tenth Edition, Clinical Modification (ICD-10-CM) code definitions from the Centers for Medicare and Medicaid Services Chronic Conditions Warehouse. Code definitions from the Agency for Healthcare Research and Quality defined potentially preventable hospitalizations where admission might have been avoided by appropriate outpatient primary care management. One in six hospitalizations in adults ≥65 years were for persons with ADRD, including 1 in 3 adults ≥85 years. Among those with ADRD-related admissions, the most common reasons for admission, as defined by the principal diagnosis, were heart disease (18.1%), certain infections (14.5%), injuries (12.7%), respiratory illness (11.2%), and genitourinary conditions (10.4%). In hospitalized adults with ADRD, the prevalence of diagnosed urinary tract infection (37.0%)—a potentially preventable hospitalization—is more than double the prevalence in adults without ADRD (15.5%, prevalence ratio = 2.39, 95% confidence interval: 2.37-2.42). Common comorbidities, injuries, and potentially preventable hospitalizations all contribute to hospitalizations in adults with ADRD. Focusing on injury prevention and appropriate outpatient management of comorbidities in adults with ADRD might reduce the number of hospitalizations, including potentially preventable hospitalizations, among adults with ADRD.

Patterns of pediatric cervical spine fractures in association with mandibular and facial fractures

ObjectivesTo determine the incidence, demographics, and outcomes of concurrent cervical spine (C-spine) fractures in pediatric facial trauma. MethodsThe Kids’ Inpatient Database (KID) from the 2016 Healthcare Cost Utilization Project (HCUP) was queried for various facial fractures using International Classification of Diseases Tenth Revision (ICD-10) diagnosis codes. Mandible fractures were further subdivided into fracture site. Patients aged 0–18 were included, and rates of C-spine fracture were analyzed with regards to demographic factors, length of stay, total charges, mortality rate, hospital characteristics, and concurrent facial fractures. ResultsOf 5568 patients included, 4.18% presented with C-spine fracture.Children with C-spine fractures were significantly older (15.02 vs 12.76 years, p < 0.001) and length of stay was significantly longer (11.33 vs 6.44 days, p < 0.001). There was no difference in rate of C-spine fracture when stratified by gender, time of week/year, hospital location/type, or facial fracture other than subcondylar fractures. Subcondylar fractures were positively associated with C-spine fractures (OR 2.08, p = 0.002). C-spine fractures were associated with significantly higher mortality, length of stay, rate of tracheostomy, transfer out of index hospital, and total hospital charges. ConclusionsA significant association exists between subcondylar mandible and C-spine fractures. Awareness of this information is vital for clinicians who manage pediatric facial trauma and alerts them to the need to rule out C-spine fractures in this group as these patients have significantly higher lengths of stay, total mean hospital costs, mortality and tracheostomy rates.

Osteoporosis-Related Fracture Events in the US

Introduction Osteoporosis is an important public health problem. Even patients who are hospitalized for fracture remain subsequently untreated. Current evidence on fracture occurrence is required to help payers and policymakers prioritize access to therapies and programs that can reduce the burden and cost of osteoporosis. Objectives To evaluate the magnitude of claims-based osteoporosis-related fractures in the US population overall and across subgroups including race/ethnicity, age, sex, and fracture site. Methods The current study used 2015 data from Medicare Standard Analytic Files (SAF), a national representation of all Medicare Fee for Service claims. In addition, commercial claim estimates were built using the following sources of data: Medicare SAF Inpatient Claims, Health Care Cost Utilization Project, CMS Hospital, US Census Bureau demographics by zip code, and commercial claims from several states. Estimates of closed fractures were quantified for hip, clinical vertebral, wrist, and other skeletal sites associated with fragility fractures that commonly occur in patients with osteoporosis using the following principal diagnosis ICD-9 codes: 805.x, 805.2x, 805.4x, 805.8x, 813.2x, 813.4x, 813.8x, 808.8x, 810.0x, 811.0x, 812.0x, 812.2x, 812.4x, 814.0x, 815.0x, 821.0x, 822.0x, 823.0x, 823.2x,823.4x, 823.8x. Results More than 2 million fractures occurred in 2015. Women accounted for 70% of fractures and 74% of the cost. Although there was a high occurrence of vertebral fractures in both men and women (18%), nonvertebral fractures represented (82%) of all fractures. They included wrist (16%), hip (20%), pelvic (7%), and other (33%; humerus, clavicle, and hand/fingers). Over 38% of the total diagnostic claims for fractures occurred in patients living in the southern region of the United States. On a state-by-state basis, Florida (8%), Texas (7%), and New York (6%) contributed to a majority of fracture events. Most fractures occurred in patients 75-84 years of age; however, the number of fracture-related claims, while steady over time compared with previous studies, remained highest in white women. Conclusions The number of osteoporosis-related fractures has escalated as predicted by earlier epidemiological studies. Treatment of osteoporosis and educational efforts in raising awareness about both osteoporosis and osteoporosis-related fractures should include all skeletal sites. Further, increased access to available therapies is warranted in the subpopulations with the highest risk.

Trends in Enteral Access Placement Among Patients With Oral Clefts: Evaluation of 46 617 Patient Admissions.

It is well known that patients with oral clefts have challenges with feeding. Enteral feeding access, in the form of gastrostomy, is often utilized to supplement or replace oral intake. Although commonly performed, these procedures have reported complication rates as high as 83%. We intend to discover rates of enteral access in patients with oral clefts and report-related outcomes. The Healthcare Cost Utilization Project Kids' Inpatient Database from 2000 to 2012 was analyzed using patients with oral clefts and enteral access procedures. The χ2 test was used for univariate analyses of proportions, and linear regression was used to analyze trends. Multivariate logistic regression was used to analyze odds ratios. Of the 46 617 patient admissions included, 14.6% had isolated cleft lip (CL), 51.7% cleft lip and palate (CLP), and 43.7% isolated cleft palate. The rates of enteral access in the oral cleft population increased from 3.7% in 2000 to 5.8% in 2012 ( P < .001). Increased rates were identified in patients with ( P = .019) and without ( P < .001) complex conditions. A significant increase in the rate of enteral access was seen in patients with CLP ( P < .001) and isolated cleft palate ( P < .001). No difference was seen in the isolated CL group ( P = .096). Patients with complex conditions were at a 4.4-fold increased risk and those admitted to urban, teaching hospitals were at a 4.7-fold risk of enteral access placement. The rates for enteral feeding access increased significantly from 2000 to 2012. The reasons for the increased incidence are unclear. Invasive enteral access procedures have been shown to have a multitude of complications. Careful patient selection should be done before placement of invasive enteral access.

Current Healthcare Utilization Patterns and Most Common Reasons for Admission Amongst Patients with Sickle Cell Disease

Background: Sickle cell disease (SCD) is an inherited condition affecting over 100,000 individuals in the United States with increasing prevalence, with annual healthcare costs of approximately $488 million dollars. Peak rates of healthcare utilization occur in the young adult population, with the highest mortality risk when transitioning to adult care. This has prompted increased efforts to improve the transition process from pediatric to adult care, in addition to optimizing overall care for SCD patients. The impact of these efforts on current healthcare utilization, including reasons for hospitalization, has yet to be explored. This study sought to explore current rates of healthcare utilization in SCD patients, measured by inpatient hospitalizations, as well as the most common reasons for hospitalization to inform continued efforts to improve outcomes in the SCD population.Methods: Data was obtained from the Healthcare Cost Utilization Project (HCUP) State Inpatient Database (SID) for New York from 2005-2014. All patients with a principal or secondary ICD-9-CM diagnosis of any genotype of SCD (282.41, 282.42, 282.60-282.64, 282.68 or 282.69) were identified. Patients with anemia or other hemoglobinopathies not due to sickle cell were excluded. The encrypted identifier was used to identify all hospitalizations in SCD patients (including those not coded for SCD), and analyze outcomes at a patient-level. Utilization outcomes examined were (1) total number of patient encounters and (2) 30-day and (3) 90-day readmissions following the index hospitalization. To examine reasons for hospitalization, variables for common conditions were created using standard ICD-9-CM diagnosis codes found in the Elixhauser Comorbidity algorithm, a tool used to predict hospital resource use and in-hospital mortality, in addition to acute or chronic conditions associated with SCD. Descriptive statistics and univariate analyses were performed using SAS Enterprise Guide version 7.1. This project was determined to be exempt from Institutional Review Board oversight per the Washington University Human Research Protection Office.Results: A total of 19,729 patients had at least one hospitalization from 2005-2014 coded for SCD, with a total of 140,779 hospitalizations. The SCD population was 57.6% female and the primary insurance type was Medicaid (49.9%). The mean age at index hospitalization was 26.5 years (SD 19.3, range 0-104) and the mean length of stay was 5.5 days (SD 11.4). At the time of the index hospitalization SCD patients aged18-30 years made up 29% of the population (Table 1). The largest percentage of all hospitalizations also occurred among patients in this age group (33.3% of total encounters). Hospitalization rates per 10 person-years of observation were similar among patients aged 10-17 years (13.2), 18-30 years (13.8), 31-45 years (12.9) and 46-64 years (13.3). Both 30-day and 90-day readmissions after the index hospitalization were highest in the 18-30 year age group (33.9% and 31.1%, respectively, Table 2). The most commonly coded diagnoses were pneumonia (23.3%), vaso-occlusive crisis (22.9%) and respiratory infection (20.1%, Table 3). The most commonly coded principal diagnosis was vaso-occlusive crisis (11.7%). Diagnoses associated with the respiratory system accounted for the largest category of hospitalization reasons, including: pneumonia (23.3%), respiratory infection (20.1%), asthma (14.5%), respiratory failure (11.0%) and chronic lung disease (14.6%). (Table 3)Conclusion: Analysis of 10 years of inpatient data shows that overall rates of hospitalizations in SCD patients have decreased as compared to those previously reported in the literature. Rates per person years were similar across most age groups, but 30-day readmission, a frequently used quality metric, was highest in the young adult age group. This suggests an improvement in utilization patterns, but also reiterates the need for targeted efforts towards improved care in the young adult group. Hospitalizations were frequently due to vaso-occlusive episodes, and a large number of hospitalizations were due to complications of the pulmonary system, both infectious and non-infectious. Directed efforts towards optimizing pulmonary health and aggressive treatment of respiratory infections may further decrease the utilization burden and hasten the improvement of outcomes in the SCD population. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Impact of Cirrhosis in Patients Who Underwent Surgical Aortic Valve Replacement

Cirrhosis is known to adversely affect cardiac surgery outcomes. Our objective was to quantify the morbidity, mortality, and cost that cirrhosis adds to surgical aortic valve replacement. From 1998 to 2011, 423,789 patients in the Nationwide Inpatient Sample Healthcare Cost Utilization Project underwent isolated aortic valve replacement; 2,769 (0.7%) had cirrhosis. Multivariable linear regression and 1:1 propensity matching were used to determine the effect of cirrhosis on postsurgical outcomes. The number of patients with cirrhosis who underwent surgical aortic valve replacement per year more than tripled during the 13-year study period. Patients with cirrhosis were more likely to be younger (p<0.0001), insured by Medicaid (p <0.0001), and operated on at an academic or high-volume hospital (p <0.05). Risk-adjusted mortality for patients with cirrhosis was 16%, compared with 5% for patients without cirrhosis. Risk factors for death included congestive heart failure, fluid and electrolyte imbalances, pulmonary circulation disorders, and weight loss. Among propensity-matched pairs, patients with cirrhosis had a higher mortality (odds ratio [OR] 3.6), risk of any complication [OR 1.5], and acute renal failure (OR 2.2). There was no increased risk of stroke, wound infection, blood transfusion, or pneumonia. The risk-adjusted length of stay (15 vs 12 days) and cost ($68,000 vs 56,000) were higher in patients with cirrhosis. In conclusion, the presence of cirrhosis poses a significant risk of death in patients who underwent surgical aortic valve replacement. When performed, the cost and length of stay are increased compared with those without cirrhosis.

The Rate of Sepsis in a National Pediatric Population, 2006 to 2012.

The rate of pediatric severe sepsis is reported to be on the rise in the United States, increasing by approximately 6000 cases annually. The goal of this study was to determine the rate of pediatric sepsis per 100 000 inpatient discharges over time. The 2006, 2009, and 2012 Agency for Healthcare Research and Quality Healthcare Cost Utilization Project Kid's Inpatient Databases were used to analyze the rate of sepsis in children over time. The rate of pediatric sepsis has increased over time from 92.8 per 100 000 in 2006 to 158.7 per 100 000 in 2012. Children less than a year old with Medicaid coverage and 3 or more procedures during hospitalization have significantly higher rates than their counterparts. This study helps clarify the population demographics that are at greater risk for sepsis infections. Understanding the at-risk population aids policymakers and care providers in targeting these populations and make drastic changes to sepsis policies.

The impact of recent hospitalization on surgical site infection after a pancreatectomy

BackgroundSurgical site infections (SSI) are a major cause of increased morbidity and cost after a pancreatectomy. Patients undergoing a pancreatectomy frequently have had recent inpatient hospital admissions prior to their surgical admission (recent pre‐surgical admission, RPSA), which could increase the risk of SSI. MethodsThe 2009–2011 Healthcare Cost Utilization Project California State Inpatient Database was used. Chi‐square tests, Student's t‐tests and multivariable logistic regression were used. ResultsThree thousand three hundred and seventy‐six patients underwent a pancreatectomy, and 444 (13.2%) had RPSA. One hundred and eighty (40.5%) RPSAs were to different hospitals other than where patients' pancreatectomy took place. In univariate analysis, patients with RPSA had a significantly higher rate of post‐operative SSIs, and this was associated with a longer length of post‐operative stay, higher post‐operative hospital costs and increased postoperative 30‐day readmission rates (Table 1). In Multivariate analysis, RPSA was an independent predictor of post‐operative SSI [odds ratio (OR) = 1.68, P= 0.013], and the risk of SSI increased with increasing RPSA length of stay (OR = 1.07 per day, P = 0.001). ConclusionsRecent pre‐surgical admission is an important risk factor for SSI after a pancreatectomy. Many patients with RPSA are not admitted pre‐operatively to the same hospital where the pancreatectomy occurs; in such circumstances, SSI rates may not be a sole reflection of the care provided by operating hospitals.