Hospital Care Data Research Articles

Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

PurposeHealth service use is most intensive in the final year of a person’s life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients’ use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage.MethodsRetrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017.ResultsA total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month.ConclusionThis study identifies two important primary care processes—home visits and anticipatory medication—associated with reduced hospital usage and intervention at the end of life.

Linking migration and hospital data in England: linkage process and evaluation of bias.

Difficulties ascertaining migrant status in national data sources such as hospital records have limited large-scale evaluation of migrant healthcare needs in many countries, including England. Linkage of immigration data for migrants and refugees, with National Health Service (NHS) hospital care data enables research into the relationship between migration and health for a large cohort of international migrants. We aimed to describe the linkage process and compare linkage rates between migrant sub-groups to evaluate for potential bias for data on non-EU migrants and resettled refugees linked to Hospital Episode Statistics (HES) in England. We used stepwise deterministic linkage to match records from migrants and refugees to a unique healthcare identifier indicating interaction with the NHS (linkage stage 1 to NHS Personal Demographic Services, PDS), and then to hospital records (linkage stage 2 to HES). We calculated linkage rates and compared linked and unlinked migrant characteristics for each linkage stage. Of the 1,799,307 unique migrant records, 1,134,007 (63%) linked to PDS and 451,689 (25%) linked to at least one hospital record between 01/01/2005 and 23/03/2020. Individuals on work, student, or working holiday visas were less likely to link to a hospital record than those on settlement and dependent visas and refugees. Migrants from the Middle East and North Africa and South Asia were four times more likely to link to at least one hospital record, compared to those from East Asia and the Pacific. Differences in age, sex, visa type, and region of origin between linked and unlinked samples were small to moderate. This linked dataset represents a unique opportunity to explore healthcare use in migrants. However, lower linkage rates disproportionately affected individuals on shorter-term visas so future studies of these groups may be more biased as a result. Increasing the quality and completeness of identifiers recorded in administrative data could improve data linkage quality.

Understanding the medical complexity of children and young people with life-limiting conditions in Wales using linked, routinely collected healthcare data

ObjectivesTo better understand the complexity and healthcare needs of children and young people in Wales with life-limiting or life threatening conditions to better plan and target healthcare services. Previous attempts to quantify complexity have required primary data collection; this is not feasible at scale, use of existing data is preferred. MethodsRoutinely collected healthcare and administrative data were linked: primary care data, hospital care data sets, cancer and congenital anomaly registries, paediatric intensive care audit data and death records. Children and young people with life-limiting conditions were identified using a previously developed diagnostic framework. Previous work on conceptualising medical complexity across eight domains was operationalised for the first time using the wide range of available data, with scores across five domains and a total complexity score. The relationship between the complexity score, healthcare use, stage of condition and category of condition was explored. ResultsChildren and young people with life-limiting conditions showed the full range of medical complexity scores, from zero to five, with distributions varying across age groups with increasing complexity at greater ages. Distributions also varied across categories of condition, with congenital and oncology conditions, although among the most prevalent, exhibiting lower medical complexity. Nonetheless, all conditions showed a range of complexities – there were no conditions for which all individuals were either high or low complexity. Complexity scores were correlated with stage of condition and healthcare use and may be used to identify groups likely to have higher healthcare demand or greater risk of clinical instability. While life-limiting conditions were more prevalent in areas of higher deprivation, there was no association between deprivation and medical complexity. ConclusionAssessment of medical complexity from routinely-collected data can be useful in better understanding a population and in targeting and planning care, without requiring additional data collection. This can help to design resilient services that prepare for changing needs and aid targeting of limited resources.

Impact of PSA testing on secondary care costs in England and Wales: estimates from the Cluster randomised triAl of PSA testing for Prostate cancer (CAP)

BackgroundScreening men for prostate cancer using prostate-specific antigen (PSA) testing remains controversial. We aimed to estimate the likely budgetary impact on secondary care in England and Wales to inform screening decision makers.MethodsThe Cluster randomised triAl of PSA testing for Prostate cancer study (CAP) compared a single invitation to men aged 50–69 for a PSA test with usual care (no screening). Routinely collected hospital care data were obtained for all men in CAP, and NHS reference costs were mapped to each event via Healthcare Resource Group (HRG) codes. Secondary-care costs per man per year were calculated, and cost differences (and population-level estimates) between arms were derived annually for the first five years following randomisation.ResultsIn the first year post-randomisation, secondary-care costs averaged across all men (irrespective of a prostate cancer diagnosis) in the intervention arm (n = 189279) were £44.80 (95% confidence interval: £18.30-£71.30) higher than for men in the control arm (n = 219357). Extrapolated to a population level, the introduction of a single PSA screening invitation could lead to additional secondary care costs of £314 million.ConclusionsIntroducing a single PSA screening test for men aged 50–69 across England and Wales could lead to very high initial secondary-care costs.

Hospital spending and length of hospital stay for mental disorders in Hunan, China

ObjectivesTo describe hospital spending and length of stay for mental disorders in Hunan, China. MethodsWe extracted hospital care data for Hunan province from the Chinese National Health Statistics Network Reporting System. Patients with mental disorders (ICD-10 codes: F00 to F99) as the principal diagnosis and hospitalized between January 1, 2017 and December 31, 2019 were included. We retrieved information on age, sex, number of comorbidities, diagnosis, level of hospital, hospital costs, date of admission and discharge, length of stay (LOS), and method of payment of eligible participants. Spending at the provincial level, and spending and LOS at the individual level were described. Quantile regression and linear regression were conducted to investigate factors for hospital cost and LOS for major mental disorders. ResultsThe 2019 annual spending on mental disorders in Hunan province was 160 million US dollars, and 71.7% was paid by insurance. The annual spending on schizophrenia was 84 million dollars, contributing to a primary burden of mental disorders. The median spending for mental disorders was $1,085 per patient, and the median hospital stay was 22 days. The study identified several significant factors associated with hospital cost and LOS, including age, sex, comorbidity, and level of the hospital. In particular, a higher level of the hospital was associated with a higher hospital spending but a shorter LOS. Women with schizophrenia had a comparable hospital spending but a significantly shorter LOS than men with schizophrenia. ConclusionHospitalization spending for patients with mental disorders is substantial. Schizophrenia is the major burden of hospitalization for mental disorders. While patients treated at a higher level of hospital had higher spending, they stayed shorter in these hospitals.

Heparin-Induced Thrombocytopenia Is Associated with Higher in-Hospital Mortality after Left Ventricular Assist Device Placement: A Retrospective Cohort Study from National Inpatient sample2016-2019

Background: Heparin is widely used to implant and maintain left ventricular assist devices (LVAD). Heparin-induced thrombocytopenia (HIT) is a severe complication that can hamper successful LVAD implantation or maintenance. The incidence and outcomes of HIT among hospitalized patients undergoing principal LVAD procedures are not well studied. Purpose: We hypothesized that HIT is not associated with increased or decreased odds of in-hospital mortality in LVAD. Methods: This is a retrospective cohort study from principal LVAD hospitalizations between January 1, 2016, and December 31, 2019, using the 2016-2019 National Inpatient Sample (NIS), the largest all-payer public database of hospital care data in the United States. Our study sample included any hospitalizations with LVAD, as a principal procedure, aged 18 years or older, using the ICD 10 procedural codes validated in previous studies. Results: From 2016 to 2019, a total of 2924 (weighted N =13,205) hospitalizations with the principal procedure as LVAD were identified. Among them, 21.96% (n= 642) were females, and 78.04% (n = 2281) were males (p &lt; 0.001), and 1.47 % (n=43) developed HIT. MeanThe mean age was 56.8 ± 13.3 years. Moreover, 60.7% of total LVAD were performed in Whites, 26.6% in Blacks, 7% in Hispanics, and 2% in Asians. 2111 (72.2%) hospitalizations had a Charlson comorbidity index (CCI) of three or higher. Compared to non-HIT, those who had HIT, were similar in age (mean age: 55.6 vs. 56.8; p=0.542), had lower CCI of three or higher (53.5% vs. 72.5%, p=0.015), but higher in-hospital mortality (23.3% vs 9.4%, p=0.006). Multivariate regression analysis showed that, compared with non-HIT, HIT had a significantly increased odds of in-hospital mortality (aOR: 3.37; 95% CI: 1.61, 7.01; p=0.001) after controlling for age, race, regional location of the hospital, hospital bed capacity, income, insurance provider, and Charlson comorbidity index. From 2016 to 2019, the annual incidence of principal LVAD per 100,000 hospitalizations have been stable at 10.1 in 2016, 10.8 in 2017, 10.2 in 2018 and 10.0 in 2019 (p-trend=0.475). Conclusion: The incidence of HIT in patients undergoing LVAD is low. However, HIT carries significantly higher in-hospital mortality in patients getting LVAD. The incidence of LVAD procedures has been stable over recent years.

Outcomes of Tumor Lysis Syndrome in Hospitalized Patients: A Retrospective Cohort Study from National Inpatient Sample 2016-2019

Background: Tumor lysis syndrome (TLS) is an oncologic emergency caused by rapid cell lysis spilling intracellular contents (potassium, phosphate, and nucleic acids) into the systemic circulation leading to hyperkalemia, hyperphosphatemia, secondary hypocalcemia, hyperuricemia, and acute kidney injury. We aim to study outcomes like in-hospital mortality, length of stay (LOS) and associated complications among TLS patients. Methods: This is a retrospective cohort study from TLS hospitalizations between January 1, 2016, and December 31, 2019, using the 2016-2019 National Inpatient Sample (NIS), the largest all-payer public database of hospital care data in the United States. Our study sample included, TLS hospitalizations with age 18 years or older, using the ICD 10 diagnosis codes validated in previous studies. Results: From 2016 to 2019, the incidence rate of TLS was 36 per 100,000 (N=10,277) hospitalizations. Among TLS admissions, 36.9% (n= 3794) were females and mean age was 63±15.5 years (P<0.001). Moreover, 67.5% were Whites, 14.7% were Blacks, 9.4% were Hispanics, and 3.7% were Asians. A total of 2494(47%) hospitalizations had a Charlson Comorbidity index (CCI) of three or higher. TLS hospitalizations were complicated by sepsis (10.6%, N=1089), Cardiac arrest (2.9%, N=298), AKI (68.8%, N=7072), ARDS (0.6%, N=64, requirement for dialysis (8.8%, N=906), GI bleed (5.5%, N=568), Non-traumatic brain hemorrhage (1.4%, N=142), Hyperkalemia (29%, N=2976), Hypocalcemia (10%, N=1042), requirement of mechanical ventilation (11%, N=1130). Mean length of stay was 13.7 days±14.6. Multivariate regression analysis showed that, the predictors for increased in-hospital mortality were GI bleed(aOR: 1.43; 95% CI: 1.16, 1.7; p=0.001), Sepsis (aOR: 2.77; 95% CI: 2.35, 3.25; p<0.001), AKI (aOR: 2.89; 95% CI: 2.49, 3.35; p<0.001), hyperkalemia (aOR: 1.54; 95% CI: 1.37, 1.73; p<0.001) after controlling for age, race ,gender, regional location of the hospital, and income. Females have higher in hospital mortality from TLS compared to males (aOR: 1.22; 95% CI: 1.09, 1.36; p=0.001). From 2016-2019, the annual incidence of TLS per 100,000 hospitalizations has been increasing at 28.6 in 2016, 33.3 in 2017, 38.3 in 2018 and 44.3 in 2019 (p-trend<0.001). Conclusion: Increased incidence of in hospital mortality could be attributed to GI bleed, hyperkalemia, sepsis, AKI. The annual incidence of TLS is rising every year.

Periprocedural outcomes of transcatheter aortic valve replacement (TAVR) in patients with and without cardiac amyloidosis-analysis from 2016–2019 national inpatient sample

Abstract Background Cardiac Amyloidosis is often misdiagnosed due to its non-specific presenting symptoms. There is a lack of evidence on the clinical outcomes in patients with cardiac amyloidosis undergoing transcatheter aortic valve replacement (TAVR). Purpose To study periprocedural outcomes in patients hospitalised primarily for TAVR with and without cardiac amyloidosis. Methods This is a retrospective observational study involving index hospitalizations for TAVR between January 1, 2016 to December 31, 2019 from the National Inpatient Sample (NIS), the largest all-payer public database of hospital care data in the United States. Our study sample included discharged adult patients (≥18 years) primarily hospitalised for TAVR using ICD-10 codes. Confounders were adjusted using multivariable regression analysis. Results During 2016–2019, there were 43270 principal hospitalizations (unweighted sample) identified for TAVR, among them 4999 patients had a history of cardiac amyloidosis. Mean age was 79.3±8.4 years. Among patients hospitalised for TAVR, 54.4% (n=23539) were males, 45.6% (n=19731) were females (p&amp;lt;0.001), 1.71% (n=740) developed cardiogenic shock, 1.53% (n=662) required mechanical ventilation with an in-hospital mortality of 1.3% (n=563). There were 87% Whites, 4.2% Blacks, 4.8% Hispanics, 1.3% Asians, and 2.7% were other races. A total of 23,819 (55.1%) hospitalizations had a Charlson Comorbidity Index (CCI) of three or higher. After undergoing TAVR, compared to the non-cardiac amyloidosis cohort, the cardiac amyloidosis cohort had less females (27.8% vs 45.6%, p=0.01), had similar age (mean age: 80.2 vs 79.3; p=0.665), higher incidence of congestive heart failure (CHF) (100% vs 74%, p=0.012), higher mechanical ventilation requirement (11.1% vs 1.5%, p=0.001)) but with a similar length of hospital stay (3.9% vs 3.9%, p=0.99). Multivariate regression analysis revealed that TAVR in cardiac amyloidosis cohort did not significantly increase the odds of in-hospital mortality than the non-cardiac amyloidosis cohort (aOR: 5.2; 95% CI: 0.7, 38.3; p=0.103). However, females had higher odds of mortality post-TAVR compared to males (aOR: 1.45; 95% CI: 1.22, 1.73; p&amp;lt;0.001) after controlling for age, sex, race, regional hospital location, hospital bed capacity, income, and CCI. There is an increasing trend of index TAVR hospitalizations with cardiac amyloidosis with 109.4 per 100,000 hospitalizations in 2016, 139.7 per 100,000 in 2017, 157.5 per 100,000 in 2018, 201.4 per 100,000 in 2019 (p trend&amp;lt;0.001). Conclusions After TAVR, cardiac amyloidosis is associated with higher incidence of CHF increased need for mechanical ventilation, similar in-hospital mortality rate in comparison to non-cardiac amyloidosis cohort. There was an increasing trend in the index hospitalizations for TAVR with cardiac amyloidosis from 2016–2019. Funding Acknowledgement Type of funding sources: None.

Outcomes of heart failure with preserved ejection fraction (HFpEF) in patients with and without cardiac amyloidosis: analysis from 2016–2019 national inpatient sample

Abstract Background Cardiac amyloidosis (CA), a restrictive cardiomyopathy that leads to heart failure, is often under-diagnosed in its early-stages, leading to patients being diagnosed with it in advanced stages. Most patients presenting with heart failure are presumed as non-amyloid heart failure due to a lack of awareness. A high degree of clinical suspicion is of paramount importance for early diagnosis and management of CA because the extent of cardiac involvement determines overall prognosis. Purpose Our study highlights the outcomes of HFpEF in patients with and without CA. Methods This is a retrospective cohort study involving principal hospitalizations for HFpEF between January 1, 2016 and December 31, 2019 from the National Inpatient Sample (NIS), the largest all-payer public database of hospital care data in the United States. Our study sample included discharged adult patients (≥18 years) hospitalised for HFpEF using ICD-10 codes validated in previous studies. Confounders were adjusted using multivariable regression analysis. Results During the study period, there were 87,219 index hospitalizations for HFpEF. Among them, 38.3% (n=33405) were males, 61.7% (n=53814) were females, and 0.24% (n=209) had CA. Racial distribution is as follows: 76% Whites, 13.4% Blacks, 6.4% Hispanics, and 4.2% other races. Mean patient age was 74.6±13.2 years, and 68.1% were on Medicare. A total of 59,135 (67.8%) hospitalizations had a Charlson Comorbidity Index (CCI) of &amp;gt;3, with an in-hospital mortality of 2.5%. Compared to the non-CA cohort, the CA cohort had lower prevalence of diabetes mellitus (8.5% vs 27%, p&amp;lt;0.0001) and COPD (23.5% vs 46.8%, p&amp;lt;0.001) but a higher prevalence of renal disease (51.6% vs 41.9%, p=0.004), cancer (25.4% vs 4.2%, p&amp;lt;0.001) and greater incidence of cardiogenic shock (5.2% vs 0.5%, p&amp;lt;0.001). Compared to the non-CA cohort, patients with CA were less likely to be female (38% vs 61.7%, p&amp;lt;0.001), were of similar age (mean age 74.7 vs 74.6 yrs, p=0.907), had longer length of hospital stay (LOS, 6.7 vs 5.1 days, p&amp;lt;0.001), higher in-hospital mortality (5.2% vs 2.5%, p=0.023), and a higher likelihood of having a CCI &amp;gt;3 (74.2% vs 67.8%, p=0.017). Multivariate regression analysis showed that subjects in the CA cohort had significantly increased adjusted odds of in-hospital mortality (aOR=2.2; 95% CI: 1.2–4.4; p=0.017) and cardiogenic shock (aOR=9.5; 95% CI: 5–17.9; p&amp;lt;0.001) than those in the non-CA cohort after adjusting for age, sex, race, and CCI. Conclusions Our study illustrates that patients with a history of CA admitted for HFpEF had greater incidence of cardiogenic shock, higher prevalence of renal diseases and cancer with a longer LOS, and higher in-hospital mortality. Funding Acknowledgement Type of funding sources: None.

Cost-effectiveness of statin therapy in categories of patients in the UK

Abstract Background Cardiovascular disease (CVD) mortality has declined steadily over the last few decades across Europe and North America. Purpose To provide contemporary estimates of long-term effectiveness and cost-effectiveness of statin therapy in different categories of patients in UK. Methods The CTT-UKB micro-simulation model, developed using the Cholesterol Treatment Trialists' Collaboration data (CTT: 118,000 participants; 5 years follow-up), and calibrated in the UK Biobank cohort (UKB: 502,000 participants; 9 years follow-up). The model integrates parametric risk equations for incident myocardial infarction, stroke, coronary revascularization, diabetes, cancer and vascular and nonvascular death, and projects annually these endpoints and survival using patient characteristics at entry. UKB data and linked primary and hospital care data informed healthcare costs in the model (2020 UK£); 2021 UK NHS Drug Tariff informed statin costs (atorvastatin 40mg at £1.22 and 80mg at £1.68 per 28 tablets); and Health Survey for England data informed health-related quality of life in the model. Previous CTT meta-analysis, atorvastatin dose-response randomized trials, and further meta-analyses of statin trials and cohort studies informed effects of 40mg/80mg atorvastatin therapy daily on rates of incident myocardial infarction, stroke, coronary revascularization, vascular death, diabetes, myopathy and rhabdomyolysis. The model was used to project gains in quality-adjusted life years (QALYs) and additional cost per QALY with lifetime use of atorvastatin 40mg or 80mg daily in categories of UKB participants by sex, age at statin initiation (40–49; 50–59 and 60–70 years), and 10-year CVD risk (QRISK3 risk (%): &amp;lt;5; 5–10, 10–15, 15–20, ≥20). Further scenarios explored effects of 5-year delay of statin initiation in people under 45 years of age or stopping statin therapy at 80 years of age. Results Across men and women in categories by age and CVD risk, lifetime use of atorvastatin 40mg daily was associated with increases in survival by 0.44–1.69 years (0.28–1.02 QALYs), and atorvastatin 80mg daily with increases in survival of 0.45–1.87 years (0.32–1.13 QALYs; Figure 1) with gains larger among participants at higher CVD risk. Both atorvastatin 40mg and 80mg doses were in the range of cost-effective treatments with incremental cost per QALY gained with atorvastatin 40mg daily versus no statin therapy below £7200/QALY and with atorvastatin 80mg vs 40mg daily below £16000/QALY (Figure 2) across all patient categories studied. Compared to lifetime statin therapy, stopping therapy at 80 years of age substantially reduced benefits and was not cost-effective in any patient category studied. Similarly, compared to immediate initiation, 5-year delay of statin therapy in 40–45 years old patients was not a cost-effective. Conclusions In the UK, statin therapy remains highly cost-effective across men and women 40–70 years old, including those at 10-year CVD risk &amp;lt;5%. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme, UK Medical Research Council (MRC), British Heart Foundation

Association of cardiac amyloidosis with valvular heart diseases – a nationwide analysis

Abstract Background Association of cardiac amyloidosis (CA) with aortic stenosis (AS) is well known. There is limited data on the association of CA with other valvular heart diseases like aortic regurgitation (AR), mitral stenosis (MS), mitral regurgitation (MR), tricuspid stenosis (TS), tricuspid regurgitation (TR), pulmonary stenosis (PS) and regurgitation (PR). Purpose To assess the associations between valvular heart diseases and cardiac amyloidosis. Methods This is a retrospective observational study from hospitalizations between January 1, 2016, and December 31, 2019, using the National Inpatient Sample (NIS), the largest all-payer public database of hospital care data in the United States. We looked into associations between valvular heart diseases (VHD) and CA. Results From 2016 to 2019, a total of 4999 patients with a history of CA, 16,711 MS, 361,864 MR, 380,072 AS, 89,452 AR, 194 TS, 104,151 TR, 853 PS, 13,277 PR were identified. Compared to those without any history of CA, those with a history of CA had significantly higher associations with MR (6.4% vs 1.3%, p&amp;lt;0.001), AS (3.6% vs 1.3%, p&amp;lt;0.001), AR (1% vs 0.3%, p&amp;lt;0.001), TS (0.02% vs 0, p&amp;lt;0.033), TR (2.7% vs 0.4%, p&amp;lt;0.001), PR (0.4% vs 0.1%, p&amp;lt;0.001). Mean age of patients with history of CA in MS (73.7 years), MR (75.2 years), AS (81.4 years), AR (77.1 years), TS (82 years), TR (77.3 years), PR (78.1 years). Compared to males, females had higher incidence of MS (0.1% vs 0.03%, p&amp;lt;0.001) and lower incidence of AS (1.2% vs 1.6%, p&amp;lt;0.001) and AR (0.3% vs 0.4%, p&amp;lt;0.001). Conclusion There was a significantly higher association between CA and MR, AS, TR. Comparatively, patients with CA and MS were younger than those with other VHD. Funding Acknowledgement Type of funding sources: None.

P665 Towards FAIR longitudinal IBD registries: preliminary results of an iterative design process of a reusable and interoperable IBD database model

Abstract Background The Real World Data [RWD] of the Dutch longitudinal IBD registries (population based IBD South Limburg cohort, Parelsnoer IBD, Initiative on Crohn and Colitis drug-registry) have proven to answer knowledge gaps regarding epidemiology, patient stratification, positioning and effectiveness and safety of new drugs. Life-long data-capture in registries for large cohorts is extremely labor intensive and expensive. Therefore, based on the database models of existing registries, we aim to develop a reusable and interoperable Real World IBD database model that will contribute re-use of every-day care data form hospital information systems and remote monitoring platforms. This project contributes to generation of high quality, multi-dimensional data for (inter)national IBD registries such as the United Registries for Clinical Assessment and Research [UR-CARE] registry and aforementioned registries. Methods The design process was iterative and involved the potential end-users of the registries. For the first iteration the database models of established Dutch IBD cohorts were taken as input, in combination with repeated discussions on the content with three principal IBD investigators. The second iteration was multifaceted including; 1) Five discussion sessions with 7 IBD researchers (MD medicine of which the majority practiced IBD care and were experienced with the hospital information system) discussing the content, and 2) four discussion sessions with researchers experienced in re-using hospital care data for research that evaluated the model on practical use and difficulties in data interpretation using the output of the first iteration. No data was analyzed, only codebooks describing variables and their values. Results The first iteration of the design phase resulted in a database model called IBD common data model [IBDCDM] v1 consisting out of 395 variables, and based on existing codebooks of Dutch IBD registries (figure 1). The database model, called IBD common data model [IBDCDM] v1 consists out of 27 independent modules on different themes important for the IBD disease course allowing for repeated data recordings (figure 2). The second iteration of the design phase resulted in pruning the modules’ content, removal of one module, merging and adding of modules. Conclusion An iterative design process involving end-users will result in higher data quality by optimizing practical usability and interpretability of the database model. Next step is to encode the model using medical standardized vocabularies (e.g. SNOMED, LOINC), for interoperability. The database model contributes towards producing reusable IBD datasets that use study hospital care data as a primary source to study the IBD disease course over several decades.

Lymphoma-Associated Pulmonary Embolism Burden in Hospital Admissions in the United States

Background: Cancer-associated pulmonary embolism (PE) is a common condition that increases morbidity and mortality among cancer patients. Lymphoma has one of the highest rates of venous thromboembolism in cancer patients. The National Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP) includes the largest all-payer inpatient hospital care data in the United States and therefore may represent a significant sample of clinically relevant pulmonary embolism in lymphoma patients. Methods: We utilized the NIS-HCUP database to extract the following data on hospitalizations from 2002 to 2014. We included in our analysis ICD-9 codes for acute PE as a primary or secondary diagnosis of admission and excluded iatrogenic, septic, chronic PE and PE related to obstetrical conditions. We divided our primary population of yielded weighted frequencies i.e. acute PE admissions into two groups: a group with lymphoma as a comorbid condition using Elixhauser comorbidity measures and a group without lymphoma. We identified baseline characteristics of each group including median age on admission, gender and race breakdown as well as common comorbidities' prevalence using Elixhauser comorbidity measures. We ran the analysis for the median length of stay, total charges, mortality scores, readmit scores and inpatient mortality using SAS software, version 9.4 (SAS Institute, Cary, North Carolina). Continuous variables were tested using Wilcoxon two-sample test. Results: We identified a total of 3,293,040 admissions of acute PE in the database from 2002 to 2014, with 98.5% (3,242,571) of the admissions in patients without lymphoma vs. 1.5% (50,469) in patients with lymphoma as a comorbidity. The breakdown of race was comparable across the two groups with the Caucasian race being predominant in lymphoma and non-lymphoma groups at 77.3% vs. 74.2% respectively [Table 1]. Male gender constituted the majority in the lymphoma group at 53.6% in contrast to the non-lymphoma group where female gender was the majority at 53.6%. [Table 2]. While median age on admission was higher in the lymphoma group compared with the non-lymphoma group (68.7 vs. 65 years respectively) , the prevalence of common comorbidities such as hypertension, paralysis, renal failure, heart failure, diabetes mellitus with and without complications were comparable across the two groups except for obesity prevalence which was higher in the non-lymphoma group. [Table 2] Median length of stay was marginally but significantly higher in the lymphoma group at 5.4 days (95% CI 5.33-5.53) vs. 4.96 (95% CI 4.95-4.97) days in the non-lymphoma group (p&lt;0.001); as were the readmission scores with a median readmission score of 30 (95% CI 29.65-30.24) vs. 14 (95% CI 13.99-14.08) for lymphoma and non-lymphoma groups, respectively (p&lt;0.001). We observed that total charges of hospitalization were significantly higher in the lymphoma group with a median of 31,899 US dollars (USD) per hospitalization (95% CI 31,174 - 32,622) compared with 27,784 USD (95% CI 27,704 - 27,864) in the non-lymphoma group. Ultimately, all-cause inpatient mortality was higher in the lymphoma group at 10.4% vs. 7.3% in the non-lymphoma group (Odds ratio 1.46, 95% CI 1.43-1.51, P-value &lt;0.0001). Median mortality score was also significantly higher in the lymphoma group at 13.15 (95% CI 12.6-13.6) vs. 5.53 (95% CI 5.50-5.55) in the non-lymphoma group (p&lt;0.001). Conclusion: Lymphoma was a comorbid diagnosis in 1.5% of patients admitted to the hospital with acute PE between 2002 and 2014 in the NIS-HCUP database. While the median age in the lymphoma group was higher, the prevalence of clinically significant comorbidities was comparable or higher in the non-lymphoma group. Lymphoma was associated with increased all-cause inpatient mortality in patients admitted with acute PE despite the study's limitation of not excluding other cancer patients from the control non-lymphoma group. Patients in the lymphoma group also had a higher risk of readmission in addition to having higher total charges per hospitalization and increased the length of stay. Efforts should continue to better prevent and treat pulmonary embolism in the lymphoma population. Disclosures No relevant conflicts of interest to declare.

Using Data From the Healthcare Cost and Utilization Project for State Health Policy Research.

The Healthcare Cost and Utilization Project (HCUP), the nation's most complete source of all-payer hospital care data, supports analyses at the national, regional, state and community levels. However, national HCUP data are often used in inappropriate ways in studies of state-specific issues. To describe the opportunities and challenges of using HCUP data to conduct state health policy research and to provide empirical examples of what can go wrong when using the national HCUP data inappropriately. Comparison of results from state-level analyses using national HCUP data and the state-specific HCUP data recommended by the Agency for Healthcare Research and Quality (AHRQ). Analyses included trends in state-specific rates of cesarean delivery and a difference-in-differences analysis of Connecticut's Medicaid expansion. Hospital discharges from the 2004 to 2011 HCUP Nationwide Inpatient Samples (NIS) and State Inpatient Databases (SID). Cesarean delivery rates, discharges per capita, and discharges by the payer. State-level estimates derived from the NIS are volatile and often provide misleading policy conclusions relative to estimates from the SID. The NIS should not be used for state-level research. AHRQ provides resources to assist analysts with state-specific studies using SID files.

Estimating the cost of status epilepticus admissions in the United States of America using ICD-10 codes

PurposeEstimate the cost of status epilepticus (SE) admissions in the USA using claim databases based on ICD-10 codes. MethodDescriptive retrospective study using national estimates for the year 2016 from the KID’s Inpatient Database (KID) for pediatric patients and from the National Inpatient Sample (NIS) for adults. These databases are comprehensive collections of all-payer, encounter-level hospital care data in the United States of America. ResultsFrom a population of 6,106,405 pediatric admissions there were 580 admissions related to SE. From a population of 29,274,158 adult admissions there were 1,405 admissions related to SE. The median (p25–p75) cost of pediatric admissions related to SE was $8,749 ($4,875–$19,067) in 2016 USA dollars [$9,295 ($5,180–$20,258) in inflation-adjusted 2019 USA dollars], and for adult admissions related to SE it was $14,678 ($7,203–$28,388) in 2016 USA dollars [$15,595 ($7,653–$30,161) in inflation-adjusted 2019 USA dollars]. Transforming to 2019 USA dollars, the values from the current study are consistent with prior estimates in the literature from the KID and NIS databases with a progressive increase, except for the cost of super-refractory SE in children that has increased disproportionately. ConclusionsThis study estimates that the cost of admissions related to SE in the USA is approximately $9,000 in children and $15,000 in adults and shows that the cost estimates have not markedly changed with the advent of ICD-10.

088 Predictors of Hospital Transfer for Patients Presenting with Priapism in Emergency Departments in the United States

Priapism is a urologic emergency which requires prompt management. There is no study in the literature that assesses the characteristics of those patients with priapism presenting to the emergency room which are transferred to another hospital for further care. We examine the patient and emergency department (ED) attributes associated with an increased likelihood of being transferred to another institution for further management. ED visits with a primary diagnosis of priapism (ICD-9 code:607.3) between 2010 and 2014 were abstracted from the Nationwide Emergency Department Sample (NEDS) (Healthcare Cost and Utilization Project, the U.S. most comprehensive source of hospital care data). Univariate and multivariate analyses were performed of patient and hospital characteristics leading to a transfer to another institution. Between 2010 and 2014 we identified a weighted estimate of 68,328 visits to the emergency department for priapism in the United States, which represents a national incidence of 4.5 cases per 100,000 male subjects per year (+/- 0.3 SE). Over the study period there was significant increasing trend towards more ED visits (EAPC=6.4%, p<0.05) and more transfers (EAPC=7.8%, p<0.05). Although, the majority of the patients were treated in the presenting hospital (94.6%), 5.4% (an estimated 3692 visits) resulted in a transfer to another institution. Patients most commonly presented in the South region (45.7%), and during weekend (32.4%) and summer months (28.1%). On multivariable analyses independent predictors of transfer to another institution included presentation to a nonteaching institution (OR 2.08, P < 0.001), non-trauma hospital (OR 1.81, p < 0.001), rural hospital (OR 1.51, p < 0.001), low ED volume (OR 1.81, p < 0.001) and very low-income level (OR 1.21, p < 0.001). Presentation in the Southern region, during the winter months, and being older than 45 years old were predictors of non-transfer.

Clinical Research Using the National Inpatient Sample: A Brief Review of Colorectal Studies Utilizing the NIS Database.

The National Inpatient Sample (NIS) is the largest collection of longitudinal hospital care data in the United States and is sponsored by the Agency for Healthcare Research and Quality. The data are collected from state organizations, hospital associations, private organizations, and the federal government. This database has been used in more than 400 disease-focused studies to examine health care utilization, access, charges, quality, and outcomes of care. The database has been maintained since 1988, making it one of the oldest on hospital data. The focus of this review is to explore and discuss the use of NIS database in colorectal surgery research and to formulate a simplified guide of the data captured for future researchers.

The Influence of Inflammatory Bowel Disease on the Outcome of Patients With Acute Stroke

Introduction: Data suggests that inflammatory bowel disease (IBD) may be associated w/ a small increased risk of stroke. However, it's not known how the copresence of IBD affects outcomes after ischemic stroke. We sought to assess the relationship between IBD & outcomes after stroke, as measured by discharge disposition, death & length of stay(LOS). Methods: Using claims data from the Healthcare Cost and Utilization Project (HCUP), we identified a cohort of patients hospitalized with a primary diagnosis of stroke from 2010-2014. HCUP includes the largest collection of all-payer, encounter-level hospital care data in the US w/ data from >7 million hospital stays each year. The predictor variable was the presence of IBD & the independent variables were discharge disposition (to home versus rehab or skilled nursing facility), death, & LOS. Logistic regression was used to analyze the association between IBD & both discharge disposition & death. Linear regression was used to analyze the association between IBD & length of stay. All regression models were adjusted for patient demographics & factors that could serve as potential confounders. Results: We identified a weighted sample of 156,456 hospitalizations for ischemic stroke. 0.5% (N=782) of the cohort carried a secondary diagnosis code of IBD, of which 47% had Crohn's disease and 53% had ulcerative colitis. Baseline demographics are in Table 1; there was a statistically significant difference between those w/ & w/o concurrent IBD, w/ regards to age (69.9 vs 72, p value 0.005), # of chronic conditions (8.9 vs 7.8, p value <0.001), & race (84.4% white vs 74.6% white, p value <0.001). The 3 outcomes of interest weren't different between the 2 groups (Table 2). When controlling for all baseline demographics, IBD wasn't associated w/ worse discharge disposition, w/ a relative risk reduction of 0.85 (95% CI 0.67-1.07) for those discharge to a facility compared to those discharged to home. When examining death as an outcome, the presence of IBD was associated with an odds ratio of 1.04 (95% CI 0.67-1.56). The presence of IBD wasn't associated w/ a significant decrease in LOS (p-value 0.88). In sub-group analysis, there were no differences between patients w/CD vs UC w/ regards to outcomes. Conclusion: The presence of IBD wasn't associated w/ worse discharge disposition, increase death, or increased LOS for individuals admitted w/ a stroke, in a nationally representative patient population.741_A Figure 1. Demographics741_B Figure 2. Outcomes

Estimating the cost of admissions related to convulsive status epilepticus in the United States of America

PurposeTo estimate the cost of admissions related to status epilepticus (SE) in the USA and to evaluate SE mortality. MethodDescriptive retrospective study using national estimates from the KID’s Inpatient Database (KID) for children and from the National Inpatient Sample (NIS) for adults for the years 2007–2012, the largest collection of all-payer, encounter-level hospital care data in the United States. The individual observation in this study is hospital admission. ResultsFrom a population of 186,013,640 admissions, a total of 184,500 admissions were related to SE. The median (p25-p75) cost of admissions related to SE was $7690 ($3893–$17,247) in the KID 2010–2012, $6529 ($3,370–$14,854) in the KID 2007–2009, $13,874 ($6699–$29,176) in the NIS 2012, $13,313 ($6,483–$28,598) in the NIS 2011, $12,999 ($6,366–$27,505) in the NIS 2010, $11,833 ($5721–$24,657) in the NIS 2009, $11,479 ($5,611–$24,326) in the NIS 2008, and $10,759 ($5493–$22,928) in the NIS 2007. Costs were more than two times higher for super-refractory SE admissions than for refractory SE admissions. Costs stratified by age followed an “U”-shaped distribution with higher costs in admissions of young children and older adults. Mortality ranged from 2.5% to 3% in children and from 12.7% to 14.9% in adults. ConclusionsThis study estimates the cost of admissions related to SE in the USA to be approximately $7000 in children and $13,000 in adults, and quantifies how costs markedly increase once SE becomes super-refractory.

A Retrospective Study of Non-Ventilator-Associated Hospital Acquired Pneumonia Incidence and Missed Opportunities for Nursing Care.

To determine non-ventilator-associated hospital-acquired pneumonia (NV-HAP) incidence, assess negative impacts on patient outcomes and cost, and identify missed preventive nursing care opportunities. NV-HAP is inadequately studied and underreported. Missed nursing care opportunities, particularly oral care, may aid NV-HAP prevention. This descriptive, observational, retrospective chart review identified adult NV-HAP cases and associated demographic and hospital care data. Two hundred five NV-HAP cases occurred in 1 year at Montefiore Medical Center, equating to an incidence of 0.47 per 1000 patient-days and an estimated excess cost of $8.2 million. ICU transfer following pneumonia occurred in 15.6% of cases. Care requirements from specialist nursing facilities increased at discharge (26.8%), as compared with care requirements on admission (17.6%). Complete nursing care documentation was missing for most patients, with oral care undocumented 60.5% of the time. Preventable NV-HAP cases and their negative impact on cost and patient outcomes may decrease through improved basic nursing care.