Higher Length Of Stay Research Articles

Antepartum Drug Dependence and Pregnancy- or Birth-related Complications: A Cross-sectional Study of 19 Million Inpatients.

ObjectiveTo evaluate the demographic characteristics, hospitalization outcomes [severity, length of stay (LOS), and total expense], and comorbidities in pregnant patients with antepartum drug dependence (ADD).MethodsWe used the national inpatient sample (NIS) and included 19,170,561 female patients (age: 12-40 years) hospitalized for pregnancy- or birth-related complications and grouped by co-diagnosis of ADD. We used descriptive statistics and Pearson’s chi-square test for categorical data and independent sample T-test for the continuous data to measure the differences in demographic and hospital outcomes. A logistic regression model was used to evaluate the odds ratio (OR) for medical and psychiatric comorbidities.ResultsThe hospitalizations with ADD declined initially, from 2010 to 2011, followed by an increase of 50% from 2011 to 2014. White pregnant females (77.5%), and those from low-income families (<25th percentile, 37.1 %) had comorbid ADD. Among medical comorbidities, iron-deficiency anemia was the most prevalent condition in pregnant inpatients (12.0% in ADD vs. 9.2% in non-ADD) followed by obesity and hypertension. Depression (12.9%) was the most prevalent psychiatric comorbidity in ADD inpatients followed by comorbid psychosis (three-fold higher odds). Among patients with substance use disorder (SUD), opioid abuse was the most prevalent one (67.3%) followed by cannabis (11.2%), cocaine (5.7%), amphetamine (4.0%), and alcohol (2.4%). Half of the pregnant inpatients with ADD had moderate severity of illness due to pregnancy or birth-related complications with four-fold higher odds [95% confidence interval (CI): 3.67-8.88]. They also had a higher LOS with a mean difference of 0.88 days (95% CI: 0.904-0.865) and had incurred higher total charges, by USD 3,797 (95% CI: 3,927-3,666), per inpatient admission for pregnancy- or birth-related complications compared to non-ADD inpatientsConclusionADD is associated with the worsening of severity of illness in pregnancy- or birth-related complications and requires acute inpatient care that leads to increased healthcare-related economic burden. The integration of SUD services with primary or maternal care is required to improve outcomes in at-risk women in the reproductive age group.

Electronic Medical Record Versus Bedside Assessment: How to Evaluate Frailty in Trauma and Emergency General Surgery Patients?

BackgroundScreening patients for frailty is traditionally done at the bedside. However, recent electronic medical record (EMR)-based, comorbidity-focused frailty assessments have been developed. Our objective was to determine how a common bedside frailty assessment, the trauma and emergency surgery (TEGS) frailty index (FI), compares to an EMR-based frailty assessment in predicting geriatric TEGS outcomes. Materials and methodsWe retrospectively reviewed our quality improvement project database consisting of TEGS patients ≥ 65 y old. Patients were screened with the TEGS FI, a 15-question bedside assessment, including comorbidities, physical activity, emotional health, and nutrition. Six of 15 items were retrievable from the enterprise data warehouse (EDW), storing all EMR data from Northwestern Memorial Hospital, and use to calculate the EDW frailty score. Patient characteristics and outcomes were compared between different groups. ResultsTwo hundred thirty-six geriatric TEGS patients were included, of which 75 (31.8%) were TEGS FI frail and 60 (25.4%) were EDW frail. TEGS FI frail patients had increased length of stay (LOS), loss of independence (LOI), and complications compared to TEGS FI nonfrail patients. EDW frail patients had higher LOS and complications than EDW nonfrail patients but similar LOI. TEGS FI and EDW frail patients had similar outcomes except TEGS FI–only patients more often have LOI. ConclusionsBedside frailty assessments and EMR-based assessments are both effective in identifying geriatric TEGS patients at risk for increased LOS and complications. However, bedside frailty screening was better at identifying patients who have LOI and may be a more appropriate choice when screening for frailty.

Outcomes of Patients With Cirrhosis Undergoing Orthopedic Procedures: An Analysis of the Nationwide Inpatient Sample.

The population of patients with cirrhosis is growing and shifting toward a more elderly demographic and thus are at risk of developing orthopedic complications. There is lack of data on safety of orthopedic procedures in this population. We performed an analysis of the Nationwide Inpatient Sample from 2005 to 2011 for patients undergoing hip arthroplasty, knee arthroplasty, and spinal laminectomy/fusion, stratified by presence of cirrhosis. The primary endpoint was in-hospital mortality and secondary endpoints included length of stay (LOS) and costs. There were 693,610 inpatient stays for orthopedic procedures conducted during the study period, with 3014 (0.43%) patients coded as having cirrhosis. Patients with cirrhosis had a lower median age (62 vs. 66 y; P<0.001) and were more likely to be male (52.3% vs. 41.1%; P<0.001). The inpatient mortality rate was significantly higher in patients with cirrhosis (2.4% vs. 0.4%; P<0.001) as was median LOS (4 vs. 3 d; P<0.001) and mean costs ($19,321 vs. $18,833; P<0.001). Patients with decompensated cirrhosis (vs. compensated cirrhosis) had significantly higher inpatient mortality rates (5.8% vs. 1.1%; P<0.001) with higher LOS and costs (P<0.001). On multivariable analysis, cirrhosis was associated with an increased risk of mortality (odds ratio, 4.22; 95% confidence interval, 2.92-6.10). Hospital cirrhosis volume was inversely associated with mortality, while hospital orthopedic procedure volumes had an inconsistent impact on outcomes. Inpatient orthopedic procedures in patients with cirrhosis result in high postoperative mortality, LOS, and costs. Careful patient selection is warranted to optimize cirrhosis patient postoperative outcomes.

Comorbid Depression and Psychosis in Parkinson's Disease: A Report of 62,783 Hospitalizations in the United States.

BackgroundDepression and psychosis are common comorbidities that significantly affects the quality of life and disease outcomes in Parkinson’s disease (PD) patients.ObjectiveThe aim of this study was to analyze and discern the differences in the hospitalization outcomes, comorbidities, and utilization of deep brain stimulation (DBS) in PD patients with comorbid depression and comorbid psychosis.MethodsWe used the Nationwide Inpatient Sample (2010-2014) and identified PD as a primary diagnosis (N = 62,783), and depression (N = 11,358) and psychosis (N = 2,475) as co-diagnosis using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Pearson’s chi-square test and independent-sample t-test were used for categorical data and continuous data, respectively.ResultsWhite male, older age, and comorbid psychosis were significantly associated with higher odds of having major severity of illness in PD inpatients. The mean length of stay (LOS) was higher in PD patients with psychosis compared to PD with depression (7.32 days vs. 4.23 days; P < 0.001), though the mean total charges of hospitalization were lower in psychosis ($31,240 vs. $38,581; P < 0.001). Utilization of DBS was lower in PD patients with psychosis versus with depression (3.9% vs. 24.3%; P < 0.001).ConclusionPsychiatric comorbidities are prevalent in PD patients and are associated with more disease severity, impaired quality of life, and increased use of healthcare resources (higher LOS and cost). They should be considered an integral part of the disease, and a multidisciplinary approach to managing this disease is crucial to improve the health-related quality of life of PD patients.

Impact of Sinus Surgery on Hospital Utilization for Complications of Sinusitis.

Sinusitis complications are potentially lethal conditions that generally require extensive treatment and thus place a significant burden on the health-care system. The purpose of this study was to assess the impact of surgery on hospital utilization associated with treatment of sinusitis complications. Retrospective cohort study using a national hospital database. The 2012 to 2013 National Inpatient Sample was queried for adult patients with sinusitis and complications. Patients were grouped based upon the presence or absence of sinus procedures. Patient demographics and health status, hospital characteristics, length of stay (LOS), and charges were determined. Of 1645 patients with sinusitis and associated complications, 232 (14%) underwent sinus procedures. These patients had higher LOS (8.0 ± 7.3 days vs 4.3 ± 5.2 days; P < .001) and charges (US$96 107 ± 108 089 vs US$30 661 ± 47 138; P < .001) than nonprocedure patients. Increased time to procedure in one operation patients (n = 209) of more than 2 days increased total LOS (11.4 ± 9.3 days vs 6.2 ± 5.5 days; P < .001) and charges (US$120 306 ± 112 748 vs US$76 923 ± 81 185; P = .005). Patients with multiple sinus procedures (n = 23) versus one had increased LOS and charges, despite no time difference from admission to first procedure (P = .35). On regression analysis, sinus procedure patients had excess LOS of 0.827 days and charges of US$36 949. Although often necessary, sinus procedures lead to increased LOS and charges. As prolonged time to sinus procedure and revision operations also increase charges, shorter trials of medical therapy and earlier surgical intervention may improve outcomes and reduce costs.

Impact of body mass index on utilization of selected hospital resources for four common surgical procedures.

Evidence about the impact of obesity on surgical resource consumption in the Australian setting is equivocal. Our objectives were to quantify the prevalence of obesity in four frequently performed surgical procedures and explore the association between body mass index (BMI) and hospital resource utilization including procedural duration, length of stay (LOS) and costs. A retrospective cohort study of patients undergoing four surgical procedures at a tertiary referral centre in New South Wales, between 1 January 2016 and 31 December 2016, was conducted. The four surgical procedures were total hip replacement, laparoscopic appendectomy, laparoscopic cholecystectomy and hysteroscopy with dilatation and curettage. Surgical groups were stratified according to BMI category. A total of 699 patients were included in the study. The prevalence of obesity was significantly higher than local and national population estimates for all procedures except appendectomy. BMI was not associated with increased hospital resource utilization (procedural, anaesthetic or intensive care stay duration) in any of the four surgical procedures examined after controlling for age, gender and complexity. For other outcomes of hospital resource utilization (LOS and cost), the relationship was inconsistent across the four procedures examined. A high BMI was positively associated with higher LOS, medical costs and allied health costs in those who underwent an appendectomy, and critical care costs in those who underwent laparoscopic cholecystectomy. Obesity was common in patients undergoing four frequently performed surgical procedures. The relationship between BMI and hospital resource utilization appears to be complex and varies across the four procedures examined.

Can CT Measures of Thoracic Muscle Provide Prognostication among Heart Transplant Recipients?

Purpose As the waitlist of heart transplant patients continues to rise, it is important to objectively identify patients who will have positive outcomes post-transplant surgery. Skeletal muscle characterization by computed tomography (CT) is prognostic in various disease states and may provide important information for selecting optimal transplant candidates. The purpose of this study was to determine the impact of CT measured muscle measures on hospital length of stay (LOS) and mortality following heart transplantation. Methods A single-center heart transplant database from 1999 to present (n=370) was used to find all patients having a pre-transplant chest CT scan and associated outcome measures of LOS and mortality (n=189). Subjects having CT scans within 6 months of transplant were analyzed separately (n=103). Pre-transplant axial CT scans were analyzed for muscle quantity (cm2) and muscle density (Hounsfield units; HU) at the 12th thoracic vertebrae (T12) and aortic arch (AA) (i.e. pectoralis muscles). Muscle quantity was further delineated by low density area (tissue with HU from 0 - 30; LDM) and normal density area (tissue with HU range from 31 - 100; NDM). Mean HU was additionally measured at a region of interest in the middle of the right pectoralis major muscle on the AA axial slice (ROI HU). Results In a multivariable Cox model, after adjusting for age and gender, patients with higher mean ROI HU had greater 1-year survival rates in both the total cohort, and in the subset of patients with CT within 6-months of transplant (HR = 0.967, p=0.032, and HR = 0.950, p=0.043, respectively). In both the total cohort and within the subset cohort, patients having increased LDM, normalized to body surface area, had lower LOS days (p=0.045 and p=0.053, respectively) and those having a higher AA ratio of NDM to LDM had higher LOS days (p=0.005 and p=0.008, respectively). No other muscle metrics at the T12 area were prognostic. Conclusion In heart transplant recipients, greater ROI HU measured by CT scan prior to transplant was associated with higher 1-year survival whereas greater LDM (indexed to body surface area) at the AA axial slice was associated with lower LOS post-transplant. Prospective trials are necessary to determine the significance of CT muscle measures at the AA to identify patients that will positively benefit from heart transplantation.

Clinical Outcomes of Infective Endocarditis in Injection Drug Users

BackgroundRising rates of hospitalization for infective endocarditis (IE) have been increasingly tied to rising injection drug use (IDU) associated with the opioid epidemic. ObjectivesThis study analyzed recent trends in IDU-IE hospitalization and characterized outcomes and readmissions for IDU-IE patients. MethodsThe authors evaluated the National Readmissions Database (NRD) for IE cases between January 2010 and September 2015. Patients were stratified by IDU status and surgical versus medical management. Primary outcome was 30-day readmission and cause, with secondary outcomes including mortality, length of stay (LOS), adjusted costs, and 180-day readmission. The Kruskal-Wallis and chi-square tests were used to analyze baseline differences by IDU status. Multivariable regressions were used to analyze mortality, readmissions, LOS, and adjusted costs. ResultsThe survey-weighted sample contained 96,344 (77.8%) non–IDU-IE and 27,432 (22.2%) IDU-IE cases. IDU-IE increased from 15.3% to 29.1% of IE cases between 2010 and 2015 (p < 0.001). At index hospitalization, IDU-IE was associated with reduced mortality (6.8% vs. 9.6%; p < 0.001) but not 30-day readmission (23.8% vs. 22.9%; p = 0.077) relative to non–IDU-IE. Medically managed IDU-IE patients had higher LOS (β = 1.36 days; 95% confidence interval [CI]: 0.71 to 2.01), reduced costs (β = −$4,427; 95% CI: −$7,093 to −$1,761), and increased readmission for endocarditis (18.1% vs. 5.6%; p < 0.001), septicemia (14.0% vs. 7.3%; p < 0.001), and drug abuse (4.3% vs. 0.7%; p < 0.001) compared with medically managed non–IDU-IE. Surgically managed IDU-IE patients had increased LOS (β = 4.26 days; 95% CI: 2.73 to 5.80) and readmission for septicemia (15.6% vs. 5.2%; p < 0.001) and drug abuse (7.3% vs. 0.9%; p < 0.001) compared with non−IDU-IE. ConclusionsThe incidence of IDU-IE continues to rise nationally. Given the increased readmission for endocarditis, septicemia, and drug abuse, IDU-IE presents a serious challenge to current management of IE.

A Descriptive Study on the Factors Affecting the Length of Stay in the Emergency Department of a Tertiary Private Hospital in the Philippines

Objective. The study aims to describe factors that contribute to the Length of Stay (LOS) in the Emergency Department (ED) patients of a Tertiary Private Hospital in Philippines.&#x0D; Methods. This is a retrospective descriptive study from September 1, 2015 to March 31, 2016 on the factors of ED consultations specifically on demographics (age and sex), payment schemes (Out of Pocket (OOP) and third party payer), shift times (morning, afternoon and night) and triage-levels were associated with LOS.&#x0D; Results. Our ED consultations with age (mean 40.75 years, SD 16.8, N 20,687, range 95) were dominated by females (56%), two age-range, 21-30 (28.4%) &amp; 31-40 and third party payer (57%). LOS (mean of 4,40 hours, SD 3,89, N 18540, range 68) was significantly higher (p&lt;0.001) on OOP patients, older age-range; 71-80, (3.5%) and 81-90, (2.3%). Emergent cases had higher incidence (X2= 30.2, p&lt;0.001) on morning shift, urgent cases on afternoon shift and trauma cases on evening shift. Non-urgent cases were consistent on all time frames. LOS was significantly higher (X2=p&lt;0.001) on urgent and emergent cases and on morning and afternoon shifts and significantly lowest, (p&lt;0.001) on night shifts.&#x0D; Conclusion. Higher LOS was associated on the following: urgent and emergent triage- levels, older age range, OOP, and morning and afternoon shifts.

PSY114 - Age-Related Hospital Utilization Among Patients with Marfan Syndrome

The objective of analysis was to examine age-related hospital utilization in patients diagnosed with Marfan syndrome (MFS), a rare connective tissue disorder affecting multiple organ systems. This non-interventional, retrospective study analyzed MFS-diagnosed patients with hospital visits between October 2015 and September 2017 in the de-identified Vizient health system database. Study cohorts were defined by age (<18, 18-35, 36-50, 51-64, >65). Univariate comparisons were analyzed using Chi-square tests for categorical and ANOVA for continuous variables. Multivariate general linear regression models were used to identify drivers of length of stay (LOS) and cost. The study population included 9,279 visits across 365 facilities. Comorbidity rates increased with age. Hypertension (1.1% vs 52.1%, p<.0001), PVD (11.9% vs 45.3% p<.0001), and CHF (3.0% vs 26.6%, p<.0001) had the largest increases from the <18 to the 65+ cohort. Some disease-related complications such as arrhythmias (1.2% vs 31.6%, p<.0001) and aortic aneurysm (1.6% vs 16.8%, p<.0001) increased between the <18 and 65+ cohorts while others such as aortic ectasia (11.0% vs 2.3%, p<.0001) and scoliosis/kyphosis (11.8% vs 3.5%, p<.0001) decreased. Older patients were more likely to be inpatients (28.6% 65+ vs 5.9% <18, p<.0001) and have higher mortality (1.6% 65+ vs 0.2% <18, p<.0001). Admission type, LOS and cost varied by cohort. The highest LOS (11.2 days) and cost ($49,590) occurred in the <18 cohort after excluding newborns. Room and board, surgery, and diagnostic testing were the largest sources of cost in the <18 cohort. Age was significantly correlated with 14 of 18 disease-related complications and 15 of 16 comorbidities. In multivariate analyses age was not an independent risk factor for increased utilization, however patient comorbidities and disease-related complications did increase utilization. Hospital resource utilization is high in MFS patients, especially those <18 years old. Disease-related complications and patient comorbidities drive resource use.

Impacto del paciente anciano en los servicios de urgencias hospitalarios

IntroductionThe aging of the population, chronic diseases, and non-urgent visits to the Emergency departments (ED) are considered the reasons for the increase of the demand of care. The aim of this study is to analyse the impact of the older population in the ED, when compared to a younger population. Material and methodsAn observational, descriptive and retrospective study including an analysis of the 92,627 patients that attended the ED in Hospitals from Health Area IV belonging to the Principality of Asturias Health Services during 2009. The analysis included the number of visits, degree of urgency when arriving at the ED, length of stay (LOS), destination after ED assessment, demand of care per time of day, laboratory tests, and radiology, complaints, and social services consultation. A comparison was made between the data of patients over and below 70 years of age. ResultsAt total of 28,965 (31.27%) patients were over 70 years of age, with a frequency rate in the ED of 52.29% (25.70% in those less than 70 years). Patients over 70 years had a higher priority attention through the Manchester triage scale, receiving more laboratory tests, with a higher LOS. They also had a higher probability of being seen by social services, of being admitted, and death. ConclusionsOlder patients consult the ED with more justifiable reasons than the younger adult population.

Is the timing of radiological intervention and treatment day associated with economic outcomes in DRG-financed health care systems: a case study

BackgroundIn 2012, Switzerland has introduced a diagnosis related group (DRG) system for hospital financing to increase the efficiency and transparency of hospital services and to reduce costs. However, little is known about the efficiency of specific processes within hospitals. The objective of this study is to describe the relationship between timing of radiological interventions, in particular scan and treatment day, and the length of stay (LOS) compliance in a hospital.MethodsThis is a cross-sectional observational study based on administrative records of all DRG cases in a Swiss university hospital in 2013, enriched by data from the radiology information system and accounting details. The data are analysed using descriptive statistics and regression methods.ResultsRadiology and related treatment on a weekend is associated with a higher LOS compliance of approximately 22.12% (p<0.01) compared to scans and treatments on weekdays, controlling for gender, age and insurance of the patient, as well as detailed medical and radiology-related factors. The higher LOS compliance is driven by emergency cases, which supports the hypothesis that for those cases on weekends more efficient scan and treatment processes are in place.ConclusionThe study provides evidence on how days of radiological intervention are related to LOS compliance in a Swiss hospital under DRG and attempts to explain how this is linked to standardised operating procedures. Our results have implications regarding potential cost savings in hospital care through alignment of care processes, infrastructure planning and guidance of patient flows.

Patient Satisfaction and Treatment Adherence for Urban Adolescents and Young Adults with Pelvic Inflammatory Disease.

Urban adolescents with pelvic inflammatory disease (PID) often seek care in emergency departments (ED). This study examines the effect of the ED patient experience - wait time (WT) and length of stay (LOS) - on satisfaction and medication adherence among urban adolescents with PID. Adolescents with PID were enrolled in an urban teaching hospital ED. Chart data were matched with 2-week interview queries about satisfaction and medication adherence. Chi-square and logistic regression analyses evaluated the relationships between WT, LOS, provider type, satisfaction, and medication adherence. Of 83 participants, 96% report satisfaction with care, but only 45% report medication adherence. Mean WT was 55 minutes and mean LOS 200 minutes. Patients with higher LOS were less adherent with medication; this relationship became non-significant after adjustments. Patients seen by trainees had much longer LOS, but no differences in satisfaction or medication adherence. Urban adolescents with PID report satisfaction with ED care despite prolonged LOS and medication adherence is poor. Optimization of ED workflows may improve outcomes in young women with PID.

Apnea in the Otherwise Healthy, Term Newborn: National Prevalence and Utilization during the Birth Hospitalization

To describe the prevalence of apnea in otherwise healthy term newborns, identify attributable length of stay (LOS) and healthcare utilization (cost) of apnea, and measure hospital variation in attributable LOS and cost of apnea in this population. We conducted a secondary analysis of a national administrative dataset, the 2012 Kids' Inpatient Database, which included 3.4 million newborn discharges in the US. The birth hospitalizations of approximately 2.6 million otherwise healthy, full-term newborns were included for analysis. Attributable LOS and cost of apnea were calculated using multivariate analyses. Apnea was diagnosed in 1 in 1000 healthy full-term newborns. Multivariate analyses showed that newborns with apnea had 0.6 days longer LOS (P < .001) and $483 greater costs (P < .001) compared with healthy term newborns, per birth hospitalization. Newborns diagnosed with apnea plus hypoxia and/or bradycardia had 1.4 days longer LOS (P < .001) and $653 greater costs (P < .001). The attributable LOS and cost attributable to apnea varied between individual hospitals and differed by hospital region. Apnea is associated with higher LOS and cost in the newborn hospitalization, with variation in hospital practice. This suggests the need for better comprehension of the underlying physiology and standardization of practice in its management in the term newborn.

The effect anticoagulation status on geriatric fall trauma patients

BackgroundThis research study aims to identify the effect of anticoagulation status on hospital course, complications, and outcomes among geriatric fall trauma patients. MethodsThe study design is a retrospective cohort study, looking at fall trauma among patients aged 60 to 80 years from 2009 to 2013 at a university hospital in the United States. The statistical analysis, conducted with SPSS software with a threshold for statistical significance of P < .05, was stratified by anticoagulation status and then further by type of anticoagulation (aspirin, warfarin, clopidogrel, enoxaparin, and dipyridamole). Outcomes variables include mortality, length of stay (LOS), intensive care unit (ICU) admission, and complications. ResultsThe total number of patients included in this study was 1,121. Compared with patients not on anticoagulation, there was a higher LOS among patients on anticoagulation (6.3 ± 6.2 vs 4.9 ± 5.2, P = .001). A higher LOS (7.2 ± 6.8 vs 5.0 ± 5.3, P = .001) and days in the ICU (2.1 ± 5.4 vs 1.1 ± 3.8, P = .010) was observed in patients on warfarin. A higher mortality (7.1% vs 2.8%, P = .013), LOS (6.3 ± 6.2 vs 5.1 ± 5.396, P = .036), and complication rate (49.1 vs 36.7, P = .010) was observed among patients on clopidogrel. ConclusionsIn this study, a higher mortality and complication rate were seen among clopidogrel, and a greater LOS and number of days in the ICU were seen in patients on warfarin. These differences are important, as they can serve as a screening tool for triaging the severity of a geriatric trauma patient's condition and complication risk. For patients on clopidogrel, it is essential that these patients are recognized early as high-risk patients who will need to be monitored more closely. For patients on clopidogrel or warfarin, bridging a patient's anticoagulation should be initiated as soon as possible to prevent unnecessary increased LOS. At last, these data also provide support against prescribing patients clopidogrel when other anticoagulation options are available.

Abstract WP371: Characteristics of Fever in Intracerebral Hemorrhage

Introduction: Fever in intracerebral hemorrhage (ICH) patients can be due to infectious or noninfectious etiology, including central mechanisms. We sought to compare patients with ICH and infectious fever to those with noninfectious fever. Methods: Among 351 consecutive primary ICH patients admitted to our institution from April 2009 to March 2010, 136 (39%) developed fever. Fever was defined as temperature &gt; 100.9°F during hospitalization. Cases were reviewed to determine if the patient had fever due to infectious versus noninfectious etiology. The diagnosis of infection was based on results of microbial cultures and National Healthcare Safety Network criteria. Other data collected included age, sex, maximum temperature (Tmax), medical history, ICH location, intraventricular hemorrhage (IVH), ICH volume as measured by standard ABC/2 bedside calculation, external ventricular drain (EVD) placement, surgical evacuation, length of stay (LOS), and inpatient mortality. Univariate analysis and multivariable logistic regression model were used to determine characteristics associated with infection status. Results: Among the 136 ICH patients with fever, 96 (71%) had noninfectious fever and 40 (29%) had infectious fever. In the univariate analysis, patients with infectious fever did not differ from patients with noninfectious fever with respect to age (61.3 vs 60.1 years, p 0.6), female sex (40% vs 48%, p 0.8), Tmax (102.2 vs 102.2°F, p 0.96), IVH (60% vs 71%, p 0.23), ICH volume (42 vs 40 cc, p 0.8), EVD placement (48% vs 51%, p 0.85), or surgical evacuation (30% vs 29%, p 1.0). Infectious fever was significantly associated with higher LOS (18.2 vs 11.1 days, p &lt;0.001), and this remained significant in survivors (18.6 vs 14.2 days, p 0.01). Noninfectious fever was associated with significantly higher inpatient mortality (35% vs 8%, p 0.0006). In multivariate analysis, infectious fever significantly correlated with prolonged LOS in survivors when dichotomized using a median of 15 days (OR 5.37, p 0.003). Conclusions: Patients with ICH who develop fever associated with an infectious etiology have longer LOS but lower in-hospital mortality. Further studies are warranted to understand fever in ICH patients.

Inpatient Costs for Patients with Inflammatory Bowel Disease and Acute Pancreatitis

Introduction: Inflammatory bowel disease (IBD) is associated with an increased risk of acute pancreatitis. Hospitalizations for acute pancreatitis in patients with IBD are anticipated to be more economically complex. Our group examined differences in length of stay (LOS) and costs for patients with IBD hospitalized for acute pancreatitis and the general population. Methods: A retrospective study of the 2005-2011 National Inpatient Sample (NIS) was conducted. The NIS is the largest publicly available inpatient healthcare database in the US. The primary diagnoses of acute pancreatitis and co-diagnoses of IBD, ulcerative colitis (UC) and Crohn's disease (CD) were identified by ICD-9 codes. Continuous variables were reported as mean ± standard deviations and compared between IBD and controls by two-sample T-tests or Wilcoxon rank-sum tests, with normality assumptions based on the Shapiro-Wilk test. Categorical variables were analyzed by Chi-square tests or Fisher's exact tests. Propensity score matching method is widely used in observational studies to reduce selection bias. To fairly compare the outcomes of interest, we conducted 1:3 propensity score matching using a matching algorithm based on following: Age, gender, race, numbers of co-morbidities, procedure number, insurance, income quartiles, hospital bed size, hospital location, region and teaching status. Statistical analyses were performed on SAS 9.3 (Cary, NC), Windows platform. Results: There were a total of 4,291 hospitalizations of IBD patients with acute pancreatitis over the 7 year period and 379,627 hospitalizations of non-IBD patients with acute pancreatitis. The mean LOS of patients with acute pancreatitis and a co-diagnosis of IBD was 5.7 days versus 4.9 days for controls (p < 0.0001). Hospital costs were higher in patients with IBD compared to controls ($29,724.89 vs. $27,916.76 respectively, p < 0.0001). Survival rates were high in both groups, but slightly lower in patients with IBD (99.4% vs. 99.3% respectively). Higher LOS and costs were seen in patients with acute pancreatitis and a co-diagnosis of CD or UC (table 1). Rate of alcohol abuse was lower and drug abuse was higher in patients with a co-diagnosis of IBD (table 2). Conclusion: Our study suggests that cost and length of stay in patients with acute pancreatitis is influenced by a co-diagnosis of IBD. A co-diagnosis of CD or UC incurs a greater economic burden in patients with acute pancreatitis.Figure 1Figure 2

Hospitalization for esophageal achalasia in the United States.

To assess the outcome of different treatments in patients admitted for esophageal achalasia in the United States. This is a retrospective analysis using the Nationwide Inpatient Sample over an 8-year period (2003-2010). Patients admitted with a primary diagnosis of achalasia were divided into 3 groups based on their treatment: (1) Group 1: patients who underwent Heller myotomy during their hospital stay; (2) Group 2: patients who underwent esophagectomy; and (3) Group 3: patients not undergoing surgical treatment. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), discharge destination and total hospital charges. Among 27141 patients admitted with achalasia, nearly half (48.5%) underwent Heller myotomy, 2.5% underwent esophagectomy and 49.0% had endoscopic or other treatment. Patients in group 1 were younger, healthier, and had the lowest mortality when compared with the other two groups. Group 2 had the highest LOS and hospital charges among all groups. Group 3 had the highest mortality (1.2%, P < 0.001) and the lowest home discharge rate (78.8%) when compared to the other groups. The most frequently performed procedures among group 3 were esophageal dilatation (25.9%) and injection (13.3%). Among patients who died in this group the most common associated morbidities included acute respiratory failure, sepsis and aspiration pneumonia. Surgery for achalasia carries exceedingly low mortality in the modern era; however, in complicated patients, even less invasive treatments are burdened by significant mortality and morbidity.

Outcomes of invasive mechanical ventilation in children and adolescents hospitalized due to status asthmaticus in United States: a population based study

Objective: Current national estimates of and outcomes of Invasive Mechanical Ventilation (MV) in status asthmaticus (SA) are unclear. The objective of this study is to estimate the incidence and outcomes of MV in hospitalized SA children and adolescents. Methods: We used the Nationwide Inpatient Sample (NIS, 2009–2010), the largest all-payer hospital discharge database in United States. All hospitalizations (age ≤21 years) with a primary diagnosis of SA were selected. MV was identified using ICD-9-CM procedure codes. Multivariable regression analyses were used to examine the association between MV and outcomes (Length of Stay (LOS) and Hospital Charges (HC)). Results: Over the study period, of the 250 718 SA hospitalizations, MV was needed for <96 h in 0.37% hospitalizations and 0.18% had MV for ≥96 h. Complications occurred in 12.4% (30 991) of all hospitalizations with pneumonia (10.8%) being the most common. A total of 65 patients died in hospitals (the overall in-hospital mortality [IHM] rate was 0.03%). About 55 of these deaths occurred among those who had MV (4% IHM rate for those receiving MV). The mean LOS and hospital HC included without MV (2.1 d, $11 921) MV < 96 h (4.8 d, $52 201); MV > 96 h (15.6 d, $200 336). After adjustment for patient/hospital level factors, the need for MV was associated with significantly higher LOS and HC (p < 0.0001). Those who had MV<96 h (OR = 2.58, 95% CI = 1.77–3.77) or MV ≥ 96 h (OR = 6.23, 95% CI = 3.87–10.03) had higher risk of developing pneumonia. Conclusions: Although MV is infrequently needed in children and adolescents hospitalized for SA (0.55% incidence rate), it is associated with higher IHM rate and significant hospital resource utilization.

Morbid Obesity (MO) Is Associated With Increased Healthcare Utilization and Is an Independent Predictor of Mortality of Acute Pancreatitis (AP)

Introduction: Obesity rates are increasing and MO (BMI≥40) adversely influences the prognosis of many gastrointestinal disorders including AP. There are no population-based studies assessing impact of MO on the outcome of acute pancreatitis (AP). The objective of this study was to evaluate the association of MO with health care resources and outcomes of AP. Methods: The nationwide inpatient sample, which is the largest inpatient care database in the United States was analyzed to identify all adult patients (≥18 years of age) hospitalized with principal diagnosis of AP (ICD-9-CM: 577.0) from 2007 to 2011. Patients with a history of bariatric surgery were excluded. ICD-9-CM codes to define MO (BMI ≥40) were: 278.01, V85.40 to V85.44. Outcomes [mortality, procedures, length of stay (LOS), and total charges] of AP were analyzed after adjusting for demographic [age, gender, race, income, insurance type, Charlson comorbidity index (CCI)], hospital (teaching status, location, region, size), and etiological differences. Results: A total of 1,337,431 inpatients with AP were identified. MO was associated with 52,659 (3.94%) of all AP admissions (MO-AP). Overall in-hospital mortality for MO-AP was significantly greater than non-MO AP (1.17% vs. 0.95%; p=0.04). Univariate analysis comparing MO-AP to non-MO AP revealed differences in all of the demographic and hospital factors. MO-AP was more frequently observed in gallstone related AP (35.5% vs. 21.5%; p<0.001), and in those with higher comorbidities (CCI ≥3, 9.6% vs. 6.8%; p<0.001) while non-MO AP was more common with alcohol related etiology (21.43% vs. 7.01%; p<0.001) and history of chronic pancreatitis (14.1% vs. 7.4%; p<0.001). Consequently, MO-AP patients underwent more cholecystectomies (21.05% vs. 11.54%; p<0.001) and ERCPs (10.6% vs. 7.9%; p <0.001). Notably, acute kidney failure (11.0% vs. 7.6%; p<0.001), respiratory failure (5.4% vs. 3.3%; p<0.001), LOS (5.9 vs. 5.1 days; p<0.001), and total hospital charges ($40,000 vs. $31,000; p<0.001) were all higher in MO-AP. Multivariate analysis revealed that MO was an independent predictor of mortality (odds ratio 1.62; 95% confidence interval 1.31, 2.01) in AP. Additionally, MO-AP patients had a higher LOS (by 0.8 days; p<0.001) and total hospitalization charges (by $7,948; p<0.001). Conclusion: Morbid obesity is an independent predictor of mortality in AP and negatively impacts inpatient hospitalization and healthcare resource utilization. With increasing rates of MO, future research should consider and evaluate its role in risk stratification scores for AP.