Higher Odds Of Inpatient Mortality Research Articles

Sequential matched analysis of racial disparities in breast cancer hospitalization outcomes among African American and White patients

BackgroundThe purpose of this study is to determine if racial disparities in inpatient outcomes persist among hospitalized patients comparing African American and White breast cancer patients matched on demographics, presentation and treatment. MethodsA total of 136,211 African American and White breast cancer patients from the Healthcare Cost and Utilization Project − Nationwide Inpatient Sample (HCUP-NIS) database, matched on demographics alone, demographics and presentation or demographics, presentation and treatment were studied. Conditional logistic regression was conducted to evaluate post-surgical complications, length of stay and in-hospital mortality outcomes. Analysis was further stratified by age (≤65 years and >65years) to evaluate whether disparities were larger in younger or older patients. All analysis was conducted using SAS 9.3. ResultsWhite women had significantly shorter hospital length of stay when matched on demographics (β=−0.87, p-value=<0.0001), demographics and presentation (β=−0.63, p-value=<0.0001), and demographics, presentation and treatment (β=−0.51, p-value=<0.0001) compared with African Americans. White women also had lower odds of mortality compared with African American women when matched on demographics (OR: 0.72, 95% CI: 0.65-0.79), demographics and presentation (OR: 0.77, 95% CI: 0.71-0.85), or matched on demographics, presentation and treatment (OR: 0.80, 95% CI: 0.73-0.88). The racial difference observed in length of stay and mortality was larger in the age group ≤65 years compared with >65years ConclusionAfrican American women experienced higher odds of inpatient mortality and longer length of stay compared with White women even after accounting for differences in demographics, presentation and treatment characteristics.

The impact of an unknown HIV serostatus on inpatient mortality.

IntroductionDetermining HIV serostatus is crucial for linking HIV-infected patients to appropriate care, which might reduce their risk of subsequent morbidity and mortality. A recent South African study demonstrated a potentially harmful association between an unknown HIV serostatus and rehospitalisation. The impact of an unknown HIV status on inpatient mortality has not yet been established in that setting, which formed the impetus for the current study.MethodsThis was an unmatched case-control analysis of adult patient data collected as part of a demographic survey at the Hlabisa Hospital, South Africa between October 2009 and February 2014. Cases were defined as patients who suffered inpatient mortality, while controls were patients who did not suffer inpatient mortality. A sample size of 92 cases and 276 controls was used in this study. Patient data related to age, gender, distance between referral clinic and the hospital, HIV serostatus (HIV-negative, HIV-positive or an unknown HIV serostatus) and comorbidity were analysed using recommended methods for unmatched case-control studies.ResultsWhen potential confounders were accounted for, we found an unknown HIV serostatus to be associated with an almost 8-fold increase in the odds of inpatient mortality when compared with patients who were known HIV-negative (Odds Ratio: 7.64, 95% Confidence Interval: 1.11-52.33, p = 0.038).ConclusionAn unknown HIV serostatus was independently associated with a higher odds of inpatient mortality. This finding highlights the potential benefit of adopting an “opt-out” approach to HIV counseling and testing. Further research on this topic is required.

P-023 Increased Risk of Opportunistic Infections in Ulcerative Colitis Patients Undergoing Hematopoietic Stem Cell Transplant

Previously we showed that ulcerative colitis (UC) patients who underwent hematopoietic stem cell transplant (HSCT) had higher inpatient mortality as compared to patients without UC (Am J Gastroenterol, 2013;108:S555–S555). In this study we sought to investigate whether the higher mortality in UC patients is linked to increased risk of opportunistic infections (OI's). We did a cross sectional study utilizing data from National Inpatient Sample (NIS) from the year 1993 to 2012. NIS is one of the largest all payer inpatient dataset in the United States. Patients with UC undergoing HSCT were identified by ICD9-CM codes 556× and 41.0× respectively. Discharge weights were used to generate nationally representative sample. Multivariate logistic regression was used to assess the impact of OI's on inpatient mortality controlling for confounders. To study the risk of OI's, we matched patients with UC to those without UC for the following criteria; age (±5 years), sex, Charlson co-morbidity index (±2), indication for HSCT, type of HSCT, source of stem cells, total body irradiation, and calendar year (±2). Rao-scott chi-square test was used to compare the outcomes. The OI's we investigated included bacterial (tuberculosis, nocardiosis, clostridium difficile, pneumococcal, legionellosis, listeriosis, nontuberculous mycobacteria), viral (cytomegalovirus, invasive herpes simplex virus), parasitic (toxoplasmosis), and fungal (pneumocystis jiroveci, invasive fungal infections {IFI}). For the years 1993 to 2012, NIS contained data on 50,330 patients who underwent HSCT (weighted N = 248,878) out of which 98 had UC (weighted N = 473). UC patients undergoing HSCT had higher risk of OI's compared to patients without UC (30.8% versus 13.6%, P < 0.0001). Among UC patients, the patients who developed OI's had higher risk of inpatient mortality compared to patients without OI's (32.6% versus 8%, P = 0.0001). In multivariate analysis, UC patients with OI's had higher odds of inpatient mortality (Odds ratio: 5.6, 95% CI; 1.2–25.7, P = 0.03) compared to UC patients without OI's. After applying matching criteria, 420 UC patients (out of 473) matched with 1277 patients without UC. In matched sample, UC patients continued to have higher risk of OI's (32.7% versus 15.7%, P = 0.0008). The higher risk of OI's in UC patients compared to patients without UC was consistent in both allogeneic (44% versus 22.3%, P = 0.009) and autologous transplants (23.6% versus 10.1%, P = 0.02). In allogeneic transplant, UC patients had higher risk of tuberculosis (2.4% versus 0%, P < 0.001) and cytomegalovirus infections (26.3% versus 2.6%, P < 0.0001) compared to patients without UC. In autologous transplant, UC patients had higher risk of IFI (11.6% versus 1.4%, P = 0.001) compared to patients without UC. There was no difference in risk of other OI's in UC patients as compared to patients without UC. In similar analysis, we found no difference in mortality and risk of OI's in patients with Crohn's disease (CD) compared to patients without CD who underwent HSCT. UC is associated with higher risk of certain OI's in patients undergoing HSCT. These OI's are associated with significantly higher odds of inpatient mortality in UC patients and may explain the increased mortality in UC patients undergoing HSCT.

Hospital Cost Associated with Veno-Occlusive Disease (VOD) in Patients with Hematopoietic Stem Cell Transplant (HSCT)

Introduction: VOD (also known as Sinusoidal Obstruction Syndrome) is a potentially life threatening complication of hematopoietic stem-cell transplantation (HSCT). Severe VOD (sVOD), defined as VOD with evidence of multi-organ dysfunction (MOD), leads to high morbidity and mortality in HSCT patients. This study assessed healthcare utilization and costs associated with VOD in patients undergoing HSCT. Methods: A retrospective cohort study was conducted using the Premier research database and had a starting population of all patients with inpatient HSCT between January 1, 2009 and May 31, 2014. The VOD cohort (all-VOD) included those who also had at least one discharge diagnosis indicating liver injury or at least two diagnoses for VOD symptoms, such as hyperbilirubinemia and/or hepatomegaly, during the study period. sVOD patients were identified using diagnoses for multi-organ dysfunction and were a subset of the VOD cohort. The non-VOD cohort was all patients from the starting cohort who did not have evidence of VOD. Primary outcomes were total hospitalization costs, hospital length of stay (LOS), and inpatient mortality. Secondary outcomes were intensive care unit (ICU) costs, ICU LOS, 30-day all-cause readmission rates and associated costs. Unadjusted descriptive analysis included Chi-squared or Wilcoxon Rank Sum tests for comparisons between cohorts, with non-VOD as the reference group. Multivariable analysis estimated the association between VOD status and primary outcomes, adjusting for differences in demographic, hospital, and clinical characteristics. Generalized linear models (GLM) were applied for total costs and LOS, and logistic regression was used for inpatient mortality. Recycled prediction was used to calculate the adjusted outcomes by VOD status. Results: A total of 5,418 patients had inpatient HSCT during the study period. The study included 291 all-VOD patients (134 sVOD and 157 non-severe VOD), in addition to 5,127 patients without evidence of VOD. Unadjusted descriptive analysis found that the all-VOD cohort had higher hospital costs (Median: $119,594, IQR: $59,793-$220,461) and longer LOS (Median: 28 days, IQR: 20-41) than the non-VOD cohort (Median cost: $62,747, IQR: $40,590-$120,974, p Discussion: This analysis is subject to limitations of administrative data. Since there is no diagnostic code for VOD, we used clinical judgment to sort through the codes most likely to be related to VOD/sVOD. Notably, the 40% mortality in the sVOD group is considerably lower than the approximately 80% mortality reported in the literature. One important reason for this difference is that our analysis measured mortality during initial HSCT hospitalization, while the higher rates in the literature are based on 100-day mortality. Additionally, our algorithm may have yielded less severe disease compared to the literature. Conclusions: VOD and sVOD were associated with increased healthcare utilization and costs compared with the HSCT patients without VOD. sVOD patients also had almost 6 times higher odds of inpatient mortality compared with patients without VOD. Disclosures Dvorak: Jazz Pharmaceuticals: Consultancy. Nejadnik: Jazz Pharmaceuticals: Employment, Equity Ownership. Cao: Premier Research Services: Employment; Jazz Pharmaceuticals: Other: Premier Research Services received funding from Jazz Pharmaceuticals for data access, study design, and analysis. Lipkin: Premier Research Services: Employment; Jazz Pharmaceuticals: Other: Premier Research Services received funding from Jazz Pharmaceuticals for data access, study design, and analysis. Robinson: Premier Research Services: Employment; Jazz Pharmaceuticals: Other: Premier Research Services received funding from Jazz Pharmaceuticals for data access, study design, and analysis. Villa: Jazz Pharmaceuticals: Employment, Equity Ownership.

Annual Hospital Volume of High Dose Interleukin-2 and Inpatient Mortality in Melanoma and Renal Cell Carcinoma Patients.

BackgroundImmunotherapy using high dose interleukin-2 (HD IL2) in patients with renal cell carcinoma (RCC) and melanoma is associated with severe toxicities. The association between annual hospital volume of HD IL2 and inpatient mortality is not well studied. In this study we aim to quantify the impact of annual hospital volume of HD IL2 on inpatient mortality using National Inpatient Sample (NIS) data.MethodsWe did a cross-sectional study using NIS, one of the largest inpatient datasets in United States, from 2003 to 2011. Patients with melanoma and RCC receiving HD IL2 were identified by ICD9 procedure code 00.15. The primary outcome was inpatient mortality. Using Joinpoint regression, which detects change in trend of inpatient mortality with change in annual volume, the hospitals were classified in three volume categories (low: 1–40, medium: 41–120, high: >120). Multivariate logistic regression was used to identify predictors of inpatient mortality controlling for confounders.ResultsFrom 2003 to 2011, 29,532 patients with RCC or melanoma who received HD IL2 were identified, and 124 died during the hospitalization (0.4%). The hospitals with low, medium and high annual volume had significant difference in inpatient mortality (0.83%, 0.29% and 0.13% respectively, p = 0.0003). On multivariate analysis, low volume hospitals were associated with significantly higher odds of inpatient mortality (OR 6.1, 95% CI 1.6–23.2, p = 0.003) as compared to high volume hospitals. Additionally, the hospitals with annual volume of 1–20 had even higher rates (1.31% vs. 0.13%, p<0.0001) and multivariate odds (OR 8.9, 95% CI 2.4–33.2, p = 0.0006) of inpatient mortality as compared to high volume hospitals.ConclusionsLower annual hospital volume of HD IL2 is associated with worse outcomes. Annual hospital volume of 1–40 and 1–20 treatments per year is associated with 6 and 9 times higher odds of inpatient mortality respectively as compared to high volume hospitals. Our findings provide preliminary evidence for a volume-outcome relationship for RCC and melanoma patients undergoing HD IL2 treatment. They support future volume-outcome analyses in relation to other anti-cancer therapies that require special training and expertise.

Hospital Cost Associated with Veno-Occlusive Disease (VOD) in Patients with Hematopoietic Stem Cell Transplant (HSCT)

Introduction: VOD (also known as Sinusoidal Obstruction Syndrome) is a potentially life threatening complication of hematopoietic stem-cell transplantation (HSCT). Severe VOD (sVOD), defined as VOD with evidence of multi-organ dysfunction (MOD), leads to high morbidity and mortality in HSCT patients. This study assessed healthcare utilization and costs associated with VOD in patients undergoing HSCT.Methods: A retrospective cohort study was conducted using the Premier research database and had a starting population of all patients with inpatient HSCT between January 1, 2009 and May 31, 2014. The VOD cohort ("all-VOD") included those who also had at least one discharge diagnosis indicating liver injury or at least two diagnoses for VOD symptoms, such as hyperbilirubinemia and/or hepatomegaly, during the study period. sVOD patients were identified using diagnoses for multi-organ dysfunction and were a subset of the VOD cohort. The non-VOD cohort was all patients from the starting cohort who did not have evidence of VOD. Primary outcomes were total hospitalization costs, hospital length of stay (LOS), and inpatient mortality. Secondary outcomes were intensive care unit (ICU) costs, ICU LOS, 30-day all-cause readmission rates and associated costs. Unadjusted descriptive analysis included Chi-squared or Wilcoxon Rank Sum tests for comparisons between cohorts, with non-VOD as the reference group. Multivariable analysis estimated the association between VOD status and primary outcomes, adjusting for differences in demographic, hospital, and clinical characteristics. Generalized linear models (GLM) were applied for total costs and LOS, and logistic regression was used for inpatient mortality. Recycled prediction was used to calculate the adjusted outcomes by VOD status.Results: A total of 5,418 patients had inpatient HSCT during the study period. The study included 291 all-VOD patients (134 sVOD and 157 non-severe VOD), in addition to 5,127 patients without evidence of VOD. Unadjusted descriptive analysis found that the all-VOD cohort had higher hospital costs (Median: $119,594, IQR: $59,793-$220,461) and longer LOS (Median: 28 days, IQR: 20-41) than the non-VOD cohort (Median cost: $62,747, IQR: $40,590-$120,974, p<0.001; Median LOS: 21 days, IQR: 16-27; p <0.001). The sVOD sub-cohort had much higher costs and LOS (Median cost: $198,436, IQR: $102,027-$406,683, p<0.001; Median LOS: 37.5 days, IQR: 27-66; p<0.001). Inpatient mortality rates in the all-VOD and sVOD groups were significantly higher than the non-VOD group (non-VOD: 3.0% vs VOD: 18.6%, p<0.001; sVOD: 39.6%, p<0.001). In multivariable regressions, the adjusted hospital costs for non-severe VOD was $8,988 higher than the non-VOD group (p=0.037), and sVOD was $41,703 higher than the non-VOD group (p<0.001). The adjusted hospital LOS for non-severe VOD was 0.90 days longer than the non-VOD group (p=0.023) and for the sVOD group was 7.02 days longer than the non-VOD group (p<0.001). The sVOD group had significantly higher inpatient mortality (10.6%) compared with non-VOD group (3.4%, Adjusted Odds Ratio=5.88, p<0.001), although the mortality difference between non-severe VOD and non-VOD groups was not significant.Discussion: This analysis is subject to limitations of administrative data. Since there is no diagnostic code for VOD, we used clinical judgment to sort through the codes most likely to be related to VOD/sVOD. Notably, the 40% mortality in the sVOD group is considerably lower than the approximately 80% mortality reported in the literature. One important reason for this difference is that our analysis measured mortality during initial HSCT hospitalization, while the higher rates in the literature are based on 100-day mortality. Additionally, our algorithm may have yielded less severe disease compared to the literature.Conclusions: VOD and sVOD were associated with increased healthcare utilization and costs compared with the HSCT patients without VOD. sVOD patients also had almost 6 times higher odds of inpatient mortality compared with patients without VOD. [Display omitted] [Display omitted] DisclosuresDvorak:Jazz Pharmaceuticals: Consultancy. Nejadnik:Jazz Pharmaceuticals: Employment, Equity Ownership. Cao:Premier Research Services: Employment; Jazz Pharmaceuticals: Other: Premier Research Services received funding from Jazz Pharmaceuticals for data access, study design, and analysis. Lipkin:Premier Research Services: Employment; Jazz Pharmaceuticals: Other: Premier Research Services received funding from Jazz Pharmaceuticals for data access, study design, and analysis. Robinson:Premier Research Services: Employment; Jazz Pharmaceuticals: Other: Premier Research Services received funding from Jazz Pharmaceuticals for data access, study design, and analysis. Villa:Jazz Pharmaceuticals: Employment, Equity Ownership.

Variation Among United States Hospitals in Inpatient Mortality for Cirrhosis

Little is known about geographic variations in health care for patients with cirrhosis. We studied geographic and hospital-level variations in care of patients with cirrhosis in the United States by using inpatient mortality as an outcome for comparing hospitals. We also aimed to identify features of patients and hospitals associated with lower mortality. We used the 2009 U.S. Nationwide Inpatient Sample to identify patients with cirrhosis, which were based on the International Classification of Diseases, 9th Revision-Clinical Modification diagnosis codes for cirrhosis or 1 of its complications (ascites, hepatorenal syndrome, upper gastrointestinal bleeding, portal hypertension, or hepatic encephalopathy). Multilevel modeling was performed to measure variance among hospitals. There were 102,155 admissions for cirrhosis in 2009, compared with 74,417 in 2003. Overall inpatient mortality was 6.6%. On multivariable-adjusted logistic regression, patients hospitalized in the Midwest had the lowest odds ratio (OR) of inpatient mortality (OR, 0.54; P < .001). Patients who were transferred from other hospitals (OR, 1.49; P < .001) or had hepatic encephalopathy (OR, 1.28; P < .001), upper gastrointestinal bleeding (OR, 1.74; P < .001), or alcoholic liver disease (OR, 1.23; P= .03) had higher odds of inpatient mortality than patients without these features. Those who received liver transplants had substantially lower odds of inpatient mortality (OR, 0.21; P < .001). Multilevel modeling showed that 4% of the variation in mortality could be accounted for at the hospital level (P < .001). Adjusted mortality among hospitals ranged from 1.2% to 14.2%. Inpatient cirrhosis mortality varies considerably among U.S. hospitals. Further research is needed to identify hospital-level and provider-level practices that could be modified to improve outcomes.

Decreased Inpatient Mortality in Obese Patients with Abdominal Nets.

Neuroendocrine tumors (NETs) of the abdomen are rare tumors with an incidence of 3.56 per 100,000 in the general population. Obesity is a growing public health problem with varying effects on severity of other disease. We investigated the association between obesity and inpatient morbidity/mortality in patients with abdominal neuroendocrine tumors utilizing the Nationwide Inpatient Sample (NIS). We analyzed data from the NIS database to investigate the association between obesity and abdominal NETs using patient information from 22,096 patient-discharges from January 1, 2009 to December 31, 2010. We demonstrate that obesity is strongly associated with decreased rates of inpatient mortality in patients with NET (OR = 0.6, multivariate P = 0.02) and that malnutrition is associated with nearly 5-fold higher odds of inpatient mortality (multivariate P < 0.0005). We did not find a statistical interaction between obesity and malnutrition; however, patients who were both malnourished and obese had a lower association with mortality risk than purely malnourished patients. Our data suggests that nutritional status may be an important factor in inpatient mortality in patients with NETs with obesity being protective.

California emergency department closures are associated with increased inpatient mortality at nearby hospitals.

Between 1996 and 2009 the annual number of emergency department (ED) visits in the United States increased by 51percent while the number of EDs nationwide decreased by 6percent, which placed unprecedented strain on the nation's EDs. To investigate the effects of an ED's closing on surrounding communities, we identified all ED closures in California during the period 1999-2010 and examined their association with inpatient mortality rates at nearby hospitals. We found that one-quarter of hospital admissions in this period occurred near an ED closure and that these admissions had 5percent higher odds of inpatient mortality than admissions not occurring near a closure. This association persisted whether we considered ED closures as affecting all future nearby admissions or only those occurring in the subsequent two years. These results suggest that ED closures have ripple effects on patient outcomes that should be considered when health systems and policy makers decide how to regulate ED closures.