Health Care Utilization Project Research Articles

Abstract A006: Disparities, social determinants of health, and ovarian cancer: predicting ovarian cancer using sociodemographic information and comorbidities as risk factors

Abstract Introduction In this study, we aimed to identify associations between ovarian cancer (OC) and patient information, including demographics and comorbidities in order to increase awareness of OC risk factors and the ways in which disparities affect individual risk. Methods Administrative data analysis was performed using Florida state inpatient data collected by the Healthcare Cost and Utilization Project in 2012. Demographic variables included age, race, insurance type, and income level. Comorbidities included hypothyroidism, diabetes, hysterectomy, obesity, alcohol abuse, and drug abuse. For each variable, descriptive and logistic regression analyses were performed using SAS software and confirmed with SPSS software to determine frequencies within binary OC outcomes and calculate associations. Results Descriptive analysis revealed that OC was most frequent in white women (73.47%) over 65 (50.17%), who were Medicare beneficiaries (57.00%) within the second quartile of annual income ($38,000-$48,000) (30.71%). Most OC patients did not have any comorbidities. Logistic regression analysis revealed higher risk of OC in women over 65 compared to younger women (OR= 4.277; 95% CI= 3.585-5.103). Black women had reduced odds of OC compared to White women (OR=0.790; 95% CI= 0.693-0.900). Privately insured women had higher odds of OC compared to women with Medicare (OR= 1.426; 95% CI= 1.245-1.634). The risk of OC was reduced in patients in the first, second, and third quartiles of annual income when compared to the highest quartile of annual income (OR= 0.606; 95% CI= 0.527-0.698, OR= 0.618; 95% CI= 0.537-0.710, OR= 0.644; 95% CI= 0.557-0.743, respectively). The risk of OC was increased in women with hypothyroidism (OR= 1.083; 95% CI= 1.021-1.148), diabetes (OR= 1.134; 95% CI= 0.973-1.331), and women who had a hysterectomy (OR= 18.543; 95% CI= 15.262-22.530), compared to those without. Odds of OC were significantly reduced in women with obesity (OR= 0.574; 95% CI= 0.503-0.654) compared to those without. Women who abused alcohol or drugs had lower odds of OC than those who did not (OR= 0.296; 95% CI= 0.205-0.426, OR= 0.280; 95% CI= 0.205-0.382, respectively). Conclusions This study identifies OC risk factors and highlights differences in the prevalence and risk of OC between women of different sociodemographic groups and between women with and without various comorbidities. Groups with socioeconomic privilege were at higher risk of OC. Financial stability and access to healthcare increase the likelihood of receiving a diagnosis, suggesting potential detection bias. Decreased risk of OC was observed in patients with stigmatized comorbidities such as obesity and substance abuse disorders. Under-investigation of symptoms is common in patients with these conditions, leading to underdiagnosis. Health and socioeconomics are inextricable, so it is necessary to understand the relationship between these aspects of patient health and OC to more accurately assess individual risk. Citation Format: Anna E. Langston, Zahra Bahrani-Mostafavi. Disparities, social determinants of health, and ovarian cancer: predicting ovarian cancer using sociodemographic information and comorbidities as risk factors [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A006.

Language-Based Disparities in Route of Hysterectomy for Benign Disease

Study ObjectiveTo assess the association between patient primary language and route of hysterectomy. DesignA retrospective cohort study was conducted using the Healthcare Cost and Utilization Project's State Inpatient Database (SID) and State Ambulatory Surgery and Services Database (SASD). SettingAll inpatient and outpatient hysterectomies from the most recent year of available data (2020–2021) from the six states that record patient primary language in the SID and SASD (Indiana, Iowa, Maryland, Michigan, Minnesota, and New Jersey) were queried. Patients or ParticipantsPatients aged 18 and over undergoing an inpatient or ambulatory hysterectomy for benign indication. InterventionsMinimally invasive hysterectomy compared to abdominal hysterectomy. Measurement and Main ResultsThe association between patient primary language (English vs. non-English) and route of hysterectomy (abdominal vs minimally invasive) was evaluated. The cohort included 52,226 patients who met inclusion criteria. The majority of patients were non-Hispanic White (71%), with a median age of 46 years (IQR 40.0–53.0). 91.4% of patients spoke English as their primary language, 3.6% spoke Spanish, and 5.0% spoke another non-English language. Patients with a non-English primary language were significantly less likely to undergo minimally invasive hysterectomy compared to patients who spoke English (OR 0.60, 95% CI 0.56–0.64, p <.001). This association remained significant following adjustments for age, race, insurance, median income, state, and fibroid, abnormal uterine bleeding, prolapse or endometriosis diagnosis (aOR 0.77, 95% CI 0.71–0.84). In a sensitivity analysis of English vs Spanish vs other non-English language, the association remained significant for other non-English languages (aOR 0.67, 95% CI 0.60–0.75) but not for Spanish (aOR 0.95, 95% CI 0.83–1.09). ConclusionPatients who are non-English speaking are significantly less likely to receive a minimally invasive hysterectomy. Addressing language disparities may improve access to a minimally invasive route of surgery, a possible surrogate for improved surgical outcomes, for our gynecologic patients.

Unplanned hospital readmission after cholecystectomy in adults with cerebral palsy.

Adults with cerebral palsy (CP) are a largely understudied, growing population with unique health care requirements. We sought to establish a deeper understanding of the surgical risk in adults with CP undergoing a common general surgical procedure: cholecystectomy. Data were obtained from the State Inpatient Database developed for the Healthcare Cost and Utilization Project. Inclusion criteria included patients ≥ 18years with CP and a primary ICD-9 procedure code indicating open or laparoscopic cholecystectomy. Demographics, procedure-related factors, and comorbid conditions were analyzed, and unplanned 30 and 90day readmission rates calculated for each variable. Reasons for readmission based on ICD-9 diagnosis codes were grouped into relevant categories. Univariate analysis identified factors significantly associated with readmission rates. A total of 802 patients with CP met the inclusion criteria. Unplanned 30 and 90day readmission rates after laparoscopic cholecystectomy were 11.4% and 18.1%, respectively. Average length of stay (LOS) after laparoscopic cholecystectomy was 7.1days. After open cholecystectomy, 30 and 90day readmission rates were 16.9% and 30.3% with an average LOS of 14.6days. Infection was the most common cause for 30 and 90day readmission. Factors associated with 30day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid diabetes and malnutrition. Factors associated with 90day readmission included type of cholecystectomy, LOS, discharge to skilled nursing facility, and comorbid heart failure, renal disease, epilepsy, and malnutrition. Unplanned readmission rates after open and laparoscopic cholecystectomy in adult patients with CP are much higher than previously demonstrated rates in the general population. These patients frequently suffer multiple comorbid conditions that significantly complicate their surgical care. As more and more of these patients live longer into adulthood, further study is warranted to grasp the perioperative risk of simple and complex surgical procedures.

Incidence of deep vein thrombosis and pulmonary embolism in closed foot and ankle fractures treated with conservative versus surgical management: A nationwide analysis

ObjectivesThough there is extensive research on recovery and outcomes of proximal joint fractures, such as hip and knee, there is a paucity of such research in foot and ankle fractures and a lack of uniform data on the incidence of venous thromboembolism (VTE). This is a retrospective cohort study that seeks to investigate the incidence of VTE following surgically versus conservatively treated foot and ankle fractures MethodsThis study included all adult-patient hospitalizations with International Classification of Disease 10th Revision diagnosis codes related to closed foot and ankle fractures as a primary diagnosis in the National Inpatient Sample, an administrative database part of the Healthcare Cost and Utilization Project, for a total of 209,595 cases. Multivariate binary logistic regression was performed to determine the effect of age, gender, past medical history of venous thromboembolism (PMHVTE), Charlson Comorbidity Index, race, surgery, and transfusion of red cell products on the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE). ResultsOur study found an overall incidence of DVT and PE to be 0.4 % and 0.3 %, respectively, following foot or ankle fracture. Conservative management was found to have an increased relative risk of DVT and PE of 2.02 and 1.15, respectively. This difference persisted on performing inverse probability treatment weighting (IPTW) analysis to account for confounders. PMHVTE and requirement of blood transfusion was associated with an increased odds ratio (OR) of 3.41 and 3.217, respectively. Cases identified as Black and Asian/Pacific Islander also had an increased OR of DVT. ConclusionsThe results of this study demonstrate that surgical management of foot and ankle fractures is associated with a lower relative risk of VTE compared to medical management. PMHVTE and transfusion of red cell products increase the odds of VTE following either form of intervention.

Interatrial Wall Abnormality is Associated with Adverse Same-Admission Outcomes Following Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is the most common joint arthroplasty procedure and is shown to be a reliable and efficacious way to improve quality of life. Individuals with interatrial wall abnormalities (IAWAs), such as atrial septal defect or patent foramen ovale (PFO), are at increased baseline risk for stroke and overall lifetime morbidity. The purpose of our study was to elucidate the association between IAWAs and perioperative TKA outcomes.We performed a retrospective cohort study utilizing the Healthcare Cost and Utilization Project National Inpatient Sample database. Admissions for TKA between 2010 and 2019 were identified using the international classification of disease (ICD)-9 and ICD-10 procedure codes. Patients with ICD-9-clinical modification (CM) diagnosis code 7455 or ICD-10-CM diagnosis code Q211 were assigned to the IAWA cohort, the primary exposure. Confounding variables included basic demographics, baseline health status, and surgical facility characteristics. The primary outcomes studied were medical complications, implant-related complications, and admission mortality. Univariate and adjusted multivariable regression analyses were used to identify associations.Compared to patients in the non-IAWA cohort, those in the IAWA cohort had significant risks for same-admission medical complications (odds ratio [OR] 5.77, 95% confidence interval [CI] 4.59-7.15; p < 0.001), implant-related complications (OR 1.55, 95% CI 1.09-2.12; p = 0.009), stroke (OR 77.46, 95% CI 58.4-101.2; p < 0.001), venous thromboembolism (VTE; OR 3.78 95% CI 2.47-5.51; p < 0.001), and mortality (OR 8.36, 95% CI 3.54-16.52; p < 0.001) following TKA.Compared to patients without IAWAs, those with IAWAs who undergo TKA have higher risks for same-admission medical and implant-related complications as well as same-admission mortality. Similarly, these patients have higher risks for same-admission stroke and VTE. Further research on perioperative TKA management in patients with IAWAs is needed.Level of Evidence is III: retrospective cohort study.

Severe Maternal Morbidity by Disability Status and Type in the United States

OBJECTIVE: To estimate the risk of severe maternal morbidity (SMM) among women with disabilities compared with those without disabilities in a nationally representative sample of U.S. delivery hospitalizations. METHODS: We conducted a retrospective cohort analysis using the 2016–2021 Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. We identified delivery hospitalizations and disability status using International Classification of Diseases, Tenth Revision diagnosis codes. The primary outcome was SMM, which was determined using 21 indicators specified by the Centers for Disease Control and Prevention. We used Poisson regression to estimate unadjusted and adjusted relative risks (aRRs) and 95% CIs for the association between disability status and type with SMM outcomes. RESULTS: Among 4,331,457 delivery hospitalizations, 128,413 (3.0%) were to women with disabilities. Women with disabilities had significantly higher rates of SMM compared with those without disabilities (396/10,000 deliveries vs 177/10,000 deliveries). In fully adjusted models, women with disabilities had an aRR of 1.86 (95% CI, 1.80–1.91) for one or more SMM indicators. The risk of SMM varied by disability type, with the highest risks observed for women who had vision disabilities (aRR 3.02, 95% CI, 2.70–3.38) or had physical disabilities (aRR 2.44, 95% CI, 2.34–2.55). Women with disabilities had the highest risk for other medical complications (puerperal cerebrovascular disorders and sickle cell disease with crisis), followed by other obstetric complications, respiratory complications, cardiovascular complications, acute renal failure, sepsis, and bleeding complications compared with women without disabilities. CONCLUSION: Women with disabilities have a significantly higher risk of SMM during delivery compared with those without disabilities, with the magnitude of risk varying by disability type. Efforts to reduce SMM and maternal mortality in the United States must prioritize the unique needs of this population and ensure equitable, disability-competent care for all women.

Identifying opportunities for community EMS fall prevention

BackgroundFalls are a leading cause of morbidity and mortality among older adults in the United States. Current fall prevention interventions rely on provider referral or enrollment during inpatient admissions and require engagement and independence of the patient. Community emergency medical services (CEMS) are a unique opportunity to rapidly identify older adults at risk for falls and provide proactive fall prevention interventions in the home. We describe the demographics and treatment characteristics of the older adult population most likely to benefit from these interventions. Materials and methodsWe linked 2019 Healthcare Cost and Utilization Project Massachusetts State Emergency Department (ED) and State Inpatient Databases with American Hospital Association survey data to query ED encounters and inpatient admissions for adults age ≥55 with ED encounters for fall-related injury between July 1, 2019 and December 31, 2019. Univariable descriptive statistics assessed participant characteristics and bivariable tests of significance compared diagnoses, disposition, and hospital characteristics between older adults with and without an EMS encounter in the six months prior to the presenting fall. ResultsOf 66,027 older adults who presented with a fall to a Massachusetts ED in July-December 2019, 7,942 (11%) had a prior encounter with EMS in the preceding six months, most of which included an injury diagnosis (99%). Compared to older adults without previous EMS encounters, those with previous EMS encounters were more often in poorer health (17% vs. 10% with multiple or complex comorbidities, p < 0.001) and of lower socioeconomic status (12% vs. 8% in lowest neighborhood income quartile, p < 0.001; 10% vs. 6% enrolled in Medicaid, p < 0.001) compared to those without a prior EMS encounter. ConclusionsA significant proportion of older adults presenting to the ED with fall related injury have encounters with EMS in the preceding months. These participants are predisposed to poorer health and economic outcomes worsened by their fall and thus demonstrate a population that would benefit from CEMS fall prevention programs.

Stroke Risk After Emergency Department Treat-and-Release Visit for a Fall.

Previous cohort studies of hospitalized patients with a delayed diagnosis of ischemic stroke found that these patients often had an initial emergency department (ED) diagnosis of a fall. We sought to evaluate whether ED visits for a fall resulting in discharge to home (ie, treat-and-release visits) were associated with increased short-term ischemic stroke risk. A case-crossover design was used to compare ED visits for falls during case periods (0-15, 16-30, 31-90, and 91-180 days before stroke) and control periods (equivalent time periods exactly 1 year before stroke) using administrative data from the Healthcare Cost and Utilization Project on all hospital admissions and ED visits across 10 states from 2016 to 2020. To identify ED treat-and-release visits for a fall and patients hospitalized for acute ischemic stroke, we used previously validated International Classification of Diseases, Tenth Revision, Clinical Modification codes. Odds ratios and 95% CIs were calculated using conditional logistic regression. Among 90 592 hospitalized patients with ischemic stroke, 5230 (5.8%) had an ED treat-and-release visit for a fall within 180 days before their stroke. Patients with an ED treat-and-release visit for a fall were older (mean age, 74.7 [SD, 14.6] versus 70.8 [SD, 15.1] years), more often female (61.9% versus 53.4%), and had higher rates of vascular comorbidities than other patients with stroke. ED treat-and-release visits for a fall were significantly more common in the 15 days before stroke compared with the 15-day control period 1 year earlier (odds ratio, 2.7 [95% CI, 2.4-3.1]). The association between stroke and a preceding ED treat-and-release visit for a fall decreased in magnitude with increasing temporal distance from stroke. ED treat-and-release visits for a fall are associated with significantly increased short-term ischemic stroke risk. These visits may be opportunities to improve stroke diagnostic accuracy and treatment in the ED.

Community level factors and racial inequities in delivery hospitalizations involving severe maternal morbidity in the United States, 2016–2019

The objective of this study was to evaluate the racial and ethnic disparities in delivery hospitalizations involving severe maternal morbidity (SMM) by location of residence and community income. We used the 2016 to 2019 Healthcare Cost and Utilization Project National Inpatient Sample. International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations with SMM. Using logistic regression models, we examined the association between race and ethnicity and delivery hospitalizations involving SMM. In adjusted analyses, the models were stratified by location of residence and community income and adjusted for patient and hospital characteristics. In rural areas, non-Hispanic Black women (AOR 1.50; 95% CI 1.25–1.79) and women of other races (AOR 1.32; 95% CI 1.03–1.69) had an increased odds of experiencing a delivery hospitalization involving SMM when compared to non-Hispanic White women. In micropolitan areas, non-Hispanic Black women (AOR 1.88; 95% CI 1.79–1.97), non-Hispanic Asian/Pacific Islander women (AOR 1.54; 95% CI 1.16–2.05), and women of other races (AOR 1.31; 95% CI 1.03–1.67) had an increased odds of experiencing a delivery hospitalization involving SMM when compared to non-Hispanic White women. Non-Hispanic Black women also had increased odds of experiencing a delivery hospitalization involving SMM in communities with the lowest income (quartile 1) (AOR 1.59; 95% CI 1.49–1.66), middle income (quartiles 2 and 3) (AOR 1.81; 95% CI 1.72–1.91), and highest income (AOR 2.09; 95% CI 1.90–2.29) when compared to non-Hispanic White women. We found that location of residence and community income are associated with racial and ethnic differences in SMM in the United States. These factors, outside of individual factors assessed in previous studies, provide a better understanding of some of the structural and systemic factors that may contribute to SMM.

Maternal and newborn outcomes in pregnancies complicated by Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. The purpose of our study was to evaluate maternal and fetal/neonatal outcomes among pregnancies complicated by GBS. We performed a retrospective cohort study using the Healthcare Cost and Utilization Project- National Inpatient Sample from the United States. ICD-9 codes were used to identify all pregnant women who delivered between 1999 and 2015 and had a diagnosis of GBS. The remaining women without GBS who delivered during that time period constituted the comparison group. The associations between maternal GBS and obstetrical and fetal/neonatal outcomes were evaluated using multivariate logistic regression, while adjusting for the confounding effects of maternal characteristics. Of 13,792,544 births included in our study, 291 were to women with GBS, for an overall incidence of 2.1/100,000 births. A steady increase in maternal GBS was observed over the study period (from 1.26 to 3.8/100,000 births, p=0.02). Further, women with GBS were more likely to have pregnancies complicated by preeclampsia, OR 1.69 (95 % CI 1.06-2.69), sepsis, 9.30 (2.33-37.17), postpartum hemorrhage, 1.83 (1.07-3.14), and to require a transfusion, 4.39 (2.39-8.05). They were also at greater risk of caesarean delivery, 2.07 (1.58-2.72) and increased length of hospital stay, 4.48 (3.00-6.69). Newborns of women with GBS were more likely to be growth restricted, 2.50 (1.48-4.23). GBS in pregnancy is associated with maternal and newborn adverse outcomes. These patients would benefit from close follow-up throughout their pregnancy and in the postpartum period.

A guide to large data sets for population-based cancer research: Strengths, limitations, and pitfalls.

With the proliferation of cancer research based on large databases, misalignment of research questions and data set capabilities is inevitable. Nationally maintained databases are appealing to cancer researchers because of the ease of access to large amounts of patient data available for analysis and risk estimation. Data sets that are commonly used in cancer research include the National Cancer Database, the SEER (Surveillance, Epidemiology, and End Results) program of the National Cancer Institute, the SEER-Medicare database, the American College of Surgeons National Surgical Quality Improvement Program, and the Healthcare Cost and Utilization Project databases, among others. Each data set has pros and cons with respect to variable availability and the ability to analyze cancer-specific outcomes. It is critical for researchers to understand the strengths and limitations of each database. Changing variable definitions, the length of postoperative data collection, and the availability of patient-reported outcomes or social determinants of health data are examples of factors that researchers must consider when selecting a data set for research purposes. For the current review, the authors summarized the advantages and disadvantages of various national data sets for cohort studies in cancer populations.

Perinatal Airway Management Mandibular Anomalies: A National Inpatient Cohort Analysis.

To characterize incidence of mandibular anomalies (MAs) and compare gestational age, airway interventions, and complications among individuals with MA phenotypes (isolated retrognathia, isolated micrognathia, syndromic micrognathia, micrognathia plus cleft palate/cleft lip and palate, agnathia/micrognathia plus cervical auricle/otocephaly, and agnathia/micrognathia plus microstomia) and unaffected individuals. The Healthcare Cost and Utilization Project Kids' Inpatient Database was used to collect data over a 20-year period beginning in 2000. Interventions were classified as perinatal when performed on day of life (DOL) 0 or 1 and subsequent when performed during the birth hospitalization after DOL 1. Hypoxic complications included cardiac arrest, birth asphyxia, hypoxic-ischemic encephalopathy, anoxic brain damage, intraventricular hemorrhage or cerebral infarction. Descriptive statistics are reported, and the Rao-Scott chi-square test compared groups. MAs affected 119 per 100,000 birth visits. Preterm delivery was more frequent for all MA phenotypes. Individuals with MA phenotypes are more likely to require medical attention (airway intervention on DOL 0 or 1 OR no airway intervention received but patient sustained hypoxic complication/mortality): 16.2%-70.7% vs. 3.8%, p < 0.01. Despite receipt of airway interventions at a higher rate, collectively individuals with MAs who received an airway intervention on DOL 0 or 1 have a mildly elevated risk of hypoxic complication or mortality (32.4% vs. 26.4%, p < 0.01). Preterm birth is more common, however, does not account for the elevated rate of airway intervention. Individuals with MAs require higher rates of medical attention, and current airway management paradigms are insufficient to prevent complications and mortality. III Laryngoscope, 2024.

2020 CMS prior authorization for hospital outpatient departments: Associated surgical volume impact

BackgroundPrior authorization is common for privately administered Medicare Advantage plans but is rarely used for surgical care when considering publicly administered plans. A 2020 Centers for Medicare and Medicaid services (CMS) policy, CMS-1717-FC, requires prior authorization for Medicare Fee-for-Service beneficiaries undergoing select procedures (blepharoplasty, abdominoplasty, botulinum toxin injection, rhinoplasty, and vein ablation) in hospital outpatient departments. The impact of this policy on surgical volume at hospital outpatient departments and shifts in care to ambulatory surgery centers is unknown. MethodsThis study used a segmented interrupted time series and pre-post logistic regression model. This study was a retrospective cohort study using data from the Healthcare Cost and Utilization Project state ambulatory surgery database and state inpatient database. ResultsFrom 2016 through 2021, a total of 272,879 patients underwent the affected procedures. Pre–CMS-1717-FC, a trend of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (–10.82, 95% confidence interval: –18.32 to –3.33, P = .01). In the post-implementation period, no change in the rate of decreasing hospital outpatient department utilization was found for Medicare Fee-for-Service beneficiaries (–3.45, 95% confidence interval: –36.15 to 29.25, P = .83). In the pre-policy period, Medicare Fee-for-Service beneficiaries were 46% less likely to use freestanding ambulatory surgery centers but 27% less likely to use hospital-owned ambulatory surgery centers. ConclusionCMS-1717-FC was not associated with significant changes in hospital outpatient department volume beyond baseline trends. Policy aiming to right-size prior authorization for these procedures and considering site-of-service will balance the need to ensure medical necessity while constraining costs.

Availability of behavioral health crisis care and associated changes in emergency department utilization.

To determine whether availability of behavioral health crisis care services is associated with changes in emergency department (ED) utilization. We used longitudinal panel data (2016-2021) on ED utilization from the Healthcare Cost and Utilization Project's State ED Databases and a novel dataset on crisis care services compiled using information from the Substance Abuse and Mental Health Services Administration's National Directories of Mental Health Treatment Facilities. A total of 1002 unique zip codes from Arizona, Florida, Kentucky, Maryland, and Wisconsin were included in our analyses. To estimate the effect of crisis care availability on ED utilization, we used a linear regression model with zip code and year fixed effects and standard errors accounting for clustering at the zip code-level. ED utilization related to mental, behavioral, and neurodevelopmental (MBD) disorders served as our primary outcome. We also examined pregnancy-related ED utilization as a nonequivalent dependent variable to assess residual bias in effect estimates. We extracted data on crisis care services offered by mental health treatment facilities (n = 14,726 facility-years) from the National Directories. MBD-related ED utilization was assessed by applying the Clinical Classification Software Refined from the Healthcare Cost and Utilization Project to the primary ICD-10-CM diagnosis code on each ED encounter (n = 101,360,483). All data were aggregated to the zip code-level (n = 6012 zip-years). The overall rate of MBD-related ED visits between 2016 and 2021 was 1610 annual visits per 100,000 population. Walk-in crisis stabilization services were associated with reduced MBD-related ED utilization (coefficient = -0.028, p = 0.009), but were not significantly associated with changes in pregnancy-related ED utilization. Walk-in crisis stabilization services were associated with reductions in MBD-related ED utilization. Decision-makers looking to reduce MBD-related ED utilization should consider increasing access to this promising alternative model.

Gender Disparity of Automatic Implantable Cardioverter-Defibrillator Placement for Primary Prevention: National Inpatient Sample Analysis.

Automatic implantable cardioverter-defibrillators (AICDs) for the primary prevention of sudden cardiac death have become standard care for patients with systolic heart failure (sHF) and ejection fraction ≤35%. While the prevalence of sHF and rates of hospitalization are higher in men, one would expect equivalent rates of implantation in women. We used the Healthcare Cost and Utilization Project's National Inpatient Sample (NIS) from 2009 to 2018 to identify patient visits with sHF and AICD implantation. The comorbidities and outcomes were compared based on gender. There were 15,247,854 inpatient admissions for sHF, of which 60.3% were males (95% CI: 60.1%-60.4%) and 39.8% females (95% CI: 39.7%-39.9%). Approximately 2% of patients (294,726) underwent the insertion of an AICD for primary prevention: 72.3% males (95% CI: 71.9%-72.7%) and 27.72% females (95% CI: 27.3%-28.1%). There was no significant difference in age (p = 0.29), length of stay (p = 0.09), and inpatient mortality (p = 0.18). In this study, women accounted for approximately 40% of patients admitted with the diagnosis of sHF; however, they accounted for less than 30% of patients who underwent the insertion of an AICD. Further research is needed to better understand this gender disparity and identify reasons for the lower rates of AICD placement in women.

Hospitalization Patterns for Rural-Residing Children from 2002 to 2017

ObjectiveThe closure of inpatient pediatric units within general hospitals has contributed to the regionalization of pediatric care. For children in rural areas, the distance traveled for hospitalization impacts the quality of care for children, the impact upon families, and the preparedness for disaster planning within rural communities. We assessed trends in location of hospitalization over time for rural-residing children. MethodsUsing the Healthcare Cost and Utilization Project’s State Inpatient Databases, we studied 256,947 hospitalizations for rural-residing children 0–17 years of age within eight states (CO, FL, KY, NC, NJ, NY, OR, WA) from 2002 to 2017. Level of rurality was defined by Rural-Urban Commuting Area Codes: micropolitan, small rural, and isolated rural. Birth, psychiatric, and surgical hospitalizations were excluded. Trends in number of hospitalizations by hospital location, interfacility transfer (IFT), and whether the hospital location was the same level of rurality as the patient’s home residence were assessed with the Cochran-Armitage trend test. ResultsFrom 2002 to 2017, hospitalizations for rural-residing children decreased by 52.7% (56,168 to 26,548) and IFTs increased from 6.7% to 26.5% (P < .001). The proportion of total hospitalizations within metropolitan areas for rural-residing children increased from 32.2% to 72.8% (P < .001). Local-area agreement between the patient’s residence and hospital utilized decreased from 53.6% to 21.5% (P < .001). ConclusionsAlthough overall hospitalizations for rural-residing children decreased, IFTs increased, and the proportion hospitalized in metropolitan areas increased. The impact of this shift in inpatient health services on efficiency and quality of care for rural-residing children needs further exploration.

Pregnancy and delivery outcomes after abdominal vs. laparoscopic myomectomy: an evaluation of an American population database

ObjectiveTo evaluate population characteristics and obstetrical complications after abdominal myomectomy vs. laparoscopic myomectomy. DesignRetrospective cohort study, using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, with hospital discharge between 2004 and 2014. SettingsPopulation-based. Subject(s)13868 and 338 pregnancies following abdominal or laparoscopic myomectomy, respectively. ExposureObstetrics outcomes following abdominal and laparoscopic myomectomy were collected. MethodsMultiple and Binomial logistic regression were used and adjusted in different models for age, obesity, chronic hypertension, and pre-gestational diabetes mellitus. Main Outcome Measure(s)Pregnancy, delivery, and neonatal outcomes were analyzed. Result(s)Abdominal myomectomy were characterized by younger patients, lower rates of Caucasian, chronic hypertension, pregestational diabetes, active smoking, illicit drug use, and higher rates of previous cesarean delivery, and multiple gestations when compared to laparoscopic myomectomy. Pregnant women with laparoscopic myomectomy had decreased rates of pregnancy-induced hypertension [adjusted risk ratios (aRR) 0.12, 95% confidence intervals (CI) 0.006-0.24)], gestational hypertension (aRR 0.24, 95%CI 0.08-0.76), preeclampsia (aRR 0.18, 95%CI 0.07-0.48), and preeclampsia or eclampsia superimposed on chronic hypertension (aRR 0.03, 95%CI 0.005-0.3), gestational diabetes mellitus (aRR 0.14, 95%CI 0.06-0.34), preterm premature rupture of membranes (aRR 0.14, 95%CI 0.02-0.96), preterm delivery (aRR 0.36, 95%CI 0.23-0.55), and cesarean delivery (CD) (aRR 0.01, 95%CI 0.007-0.01) and small for gestational age (aRR 0.15, 95%CI 0.005-0.04), compared to abdominal myomectomy group. Laparoscopic myomectomy group had a higher rate of spontaneous aRR 35.57, 95%CI 22.53-62.66), and operative vaginal delivery (aRR 10.2, 95%CI 8.3-12.56), uterine rupture (aRR 6.1. 95%CI 3.2-11.63), postpartum hemorrhage (aRR 3.54, 95%CI 2.62-4.8), hysterectomy (aRR 7.74, 95%CI 5.27-11.4), transfusion (aRR 3.34, 95%CI 2.54-4.4), pulmonary embolism (aRR 7.44, 95%CI 2.44-22.71), disseminated intravascular coagulation (aRR 2.77, 95% CI 1.47-5.21), maternal infection (aRR 1.66, 95%CI 1.1-2.5) and death (aRR 2.04 95%CI 1.31-3.2)) and intra-uterine fetal death (aRR 2.99, 95%CI 1.72-5.2) compared to the abdominal myomectomy group. ConclusionsWomen who had a previous abdominal myomectomy have underlying risk factors for hypertension disorders of pregnancy and gestational diabetes. Women who underwent laparoscopic myomectomies have higher risks of bleeding, uterine rupture, resultant complications, and death, and should be monitored as high-risk patients, like abdominal myomectomies.

Non-COVID Respiratory Infections Related Emergency Room Visits Among Autistic Adults in the United States

IntroductionThis is a retrospective study to examine the risk of non-COVID-19 respiratory infection (RI) related emergency department (ED) visits and hospitalizations among autistic adults compared to non-autistic adults using the 2018 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (HCUP-NEDS). MethodsThe data were analyzed in 2022 using the ICD-10-CM codes to extract about 46,996 autistic case records that were matched by age and sex with non-autistic records (140,997) in a 1:3 case-control ratio. Respiratory infections were also identified using the ICD-10-CM codes and classified by type. Logistic regression models were conducted for the likelihood of presenting with RI infections to the ED and subsequent hospitalization. All models were adjusted for covariates. ResultsAutistics were more likely to present with any type of respiratory infection at the emergency department (AOR = 1.83: CI= 1.69-2.42), lower respiratory infections (AOR=1.37: CI=1.09-1.50), and pneumonia (AOR=2.42: CI=1.98-2.47) compared to non-autistics. They are also more likely to be hospitalized from RIs during ED visits (AOR=3.87: CI=3.21-4.30), including upper and lower RIs, pneumonia, and bronchitis. ConclusionsAutistic individuals were more likely to experience emergency department visits and hospitalizations due to respiratory infections compared to non-autistic individuals. Amid growing evidence of the disproportionate impact of COVID-19 on the autistic population, our findings highlight a broader, pre-existing burden of respiratory infections among autistic adults in the US that extends beyond the recent pandemic.

Potentially Avoidable Emergency Department Transfers for Acute Pediatric Respiratory Illness

BackgroundAcute pediatric respiratory illness is one of the most common reasons for emergency department (ED) transfer; however, few studies have examined predictors of potentially avoidable ED transfer (PAT) in this subpopulation. This study aimed to characterize patterns and predictors of PATs in children with acute respiratory illness. MethodsCross-sectional analysis of 8,402,577 visits for patients ≤17 years from 2018 to 2019 Health Care Utilization Project State ED and Inpatient Datasets from New York, Maryland, Wisconsin, and Florida. ED transfers matched to a visit at a receiving facility with a primary diagnosis of pneumonia, croup/other URI, bronchiolitis, or asthma were included. PAT was defined as discharge from receiving ED or within 24 hours of inpatient admission without specialized procedures, as previously described. PATs were compared with necessary transfers using a 3-level generalized linear mixed model with adjustment for patient and hospital covariates. ResultsAmong 4409 matched respiratory transfers, 25.5% were potentially avoidable. Most PATs originated from EDs within the third highest quartile of annual pediatric ED visits (n = 472, 42.0%). In the multivariable model, the likelihood of PAT was higher for patients with croup/other URI (OR 2.72 (2.09–3.5) and if referring ED was in the highest quartile of annual pediatric ED volumes (OR 0.48 95% CI 0.26–0.88). ConclusionsPediatric respiratory transfers with a diagnosis of croup/other URI were the most likely to be potentially avoidable. Future implementation efforts to reduce PATs should consider focusing on croup management in EDs in the lower 3 quartiles of pediatric volume.

Interhospital transfer dynamics for patients with intracranial hemorrhage in Massachusetts.

Intracranial hemorrhages present across a spectrum of clinical phenotypes, with many patients transferred across hospitals to access higher levels of neurocritical care. We sought to characterize patient dispositions following intracranial hemorrhage and examine disparities associated with interhospital transfers. Using the Healthcare Cost and Utilization Project database, we mapped and identified factors influencing the likelihood of patient transfers and receipt of specialist interventional procedures following intracranial hemorrhage. Of 11,660 patients with intracranial hemorrhage, 59.4% had non-traumatic and 87.5% single compartment bleeds. After presentation, about a quarter of patients were transferred to another facility either directly from the ED (23.0%) or after inpatient admission (1.8%). On unadjusted analysis, patients who were white, in the upper income quartiles, with private insurance, or resided in suburban areas were more frequently transferred. After adjusting for patient-and hospital-level variables, younger and non-white patients had higher odds of transfer. Hospital capabilities, residence location, insurance status, and prior therapeutic relationship remained as transfer predictors. Transferred patients had a similar hospital length of stay compared to admitted patients, with 43.1% having no recorded surgical or specialist interventional procedure after transfer. Our analysis reveals opportunities for improvement in risk stratification guiding transfers, as well as structural challenges likely impacting transfer decisions.