Hospital Encounters Research Articles

Trends in Percutaneous Device Use for the Treatment of Venous Thromboembolism Over Time in the PINC AI Healthcare Database and the National Inpatient Sample

The number of different methodologies of reperfusion therapy to treat venous thromboembolism (VTE) has increased substantially. Nevertheless, investigation of data representativeness and device-level usage in administrative databases has been limited. Using the National Inpatient Sample (NIS) and the PINC AI Healthcare Database (PHD), all hospital encounters with a diagnosis code of VTE were identified between 1/1/2016 and 12/31/2020. Patient demographics and trends in treatment modalities were evaluated over time. An algorithm was developed to identify specific devices used for VTE treatment in the PHD cohort. 145,870 VTE patients treated with reperfusion therapy were identified in the NIS (Pulmonary embolism (PE): 88,725; isolated DVT (iDVT): 57,145) and 39,311 in the PHD (PE: 25,383; iDVT: 13,928). Patient demographics were qualitatively similar in the NIS and PHD. Over time, there was a significant increase in the use of mechanical thrombectomy (MT) in the PE and iDVT populations (p<0.05 in both databases) with catheter directed thrombolysis (CDT) use plateauing in PE (p=0.83 and p=0.14 in NIS and PHD respectively) and significantly decreasing for the iDVT population (p<0.05 in both databases). In the PHD cohort, specific reperfusion devices were identified in 14,105 patients (PE: 9,098; iDVT: 5,007). In conclusion, the use of MT for the treatment of VTE has increased over time, while rates of CDT therapy have remained stagnant or decreased. Further research is needed to understand the uptake of these treatment modalities as well as the unique abilities of the PHD to study specific device therapy in the VTE population.

Appendicitis Hospitalization Care Costs Among Patients With Delayed Diagnosis of Appendicitis

Delayed appendicitis diagnosis is associated with worse outcomes. Appendicitis hospital care costs associated with delayed diagnosis are unknown. To determine whether delayed appendicitis diagnosis was associated with increased appendicitis hospital care costs. This cohort study used data from patients receiving an appendectomy aged 18 to 64 years in 5 states (Florida, Maryland, Massachusetts, New York, Wisconsin) that were captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases for the years 2016 and 2017 with no additional follow-up. Data were analyzed January through April 2023. Delayed diagnosis was defined as a previous emergency department or inpatient hospital encounter with an abdominal diagnosis other than appendicitis, and no intervention 7 days prior to appendectomy encounter. The main outcome was appendicitis hospital care costs. This was calculated from aggregated charges of encounters 7 days prior to appendectomy, the appendectomy encounter, and 30 days postoperatively. Cost-to-charge ratios were applied to charges to obtain costs, which were then adjusted for wage index, inflation to 2022 US dollar, and with extreme outliers winsorized. A multivariable Poisson regression estimated appendicitis hospital care costs associated with a delayed diagnosis while controlling for age, sex, race and ethnicity, insurance status, care discontinuity, income quartile, hospital size, teaching status, medical school affiliation, percentage of Black and Hispanic patient discharges, core-based statistical area, and state. There were 76 183 patients (38 939 female [51.1%]; 2192 Asian or Pacific Islander [2.9%], 14 132 Hispanic [18.5%], 8195 non-Hispanic Black [10.8%], 46 949 non-Hispanic White [61.6%]) underwent appendectomy, and 2045 (2.7%) had a delayed diagnosis. Delayed diagnosis patients had median (IQR) unadjusted cost of $11 099 ($6752-$17 740) compared with $9177 ($5575-$14 481) for nondelayed (P < .001). Patients with delayed diagnosis had 1.23 times (95% CI, 1.16-1.28 times) adjusted increased appendicitis hospital care costs. The mean marginal cost of delayed diagnosis was $2712 (95% CI, $2083-$3342). Even controlling for delayed diagnosis, non-Hispanic Black patients had 1.22 times (95% CI, 1.17-1.28 times) the adjusted increased appendicitis hospital care costs compared with non-Hispanic White patients. In this cohort study, delayed diagnosis of appendicitis was associated with increased hospital care costs.

Aesthetic Surgery Complications Disproportionately Burden Economically Disadvantaged Patients and Financially Strain Public Health Insurance: A Single Academic Center Retrospective Analysis

Abstract Goals/Purpose Complications of elective aesthetic surgery performed in private practice pose significant morbidity to patients and resource burden to healthcare systems. We aimed to characterize contemporary demographic and complication patterns among patients presenting to an academic center after aesthetic surgery, as well as the financial and resource burden of their postoperative care on the hospital and payor. Methods/Technique We performed a retrospective review of patients who presented to an urban, academic hospital emergency department in Northern California from September 1, 2020 to September 30, 2023. We included patients with primary complaints related to aesthetic procedures performed at outside centers resulting in a plastic surgery consultation. Demographics, outcomes, hospital charges, and insurance payments were determined. Univariable analyses identified associations with outcomes. Results/Complications We identified 36 patients with aesthetic procedure-related complaints. Mean age was 37.5 ± 9.8 years and all patients were female. Compared with the rest of the patient population presenting to the emergency department over the same time period (n=269,286), the identified patients were more likely to be black (34.3% vs. 20.4%, p=.04), Hispanic (40% vs. 24.6%, p=.03), and on Medicaid (80.6% vs. 31.7%, p&amp;lt;.001). Tobacco/cannabis use and obesity were prevalent in 25% and 47.2% of patients, respectively. Most patients underwent aesthetic procedures in the United States (51.4%), followed by Mexico (37.1%) and the Dominican Republic (11.4%). Body regions intervened upon were the abdomen (52.8%), breasts (52.8%), buttocks (33.3%), and arms (8.3%). In 36.1% of patients, multiple body regions were intervened upon during the index case. Abdominal cases included primary abdominoplasty (84.2%), panniculectomy (10.5%), and revision abdominoplasty (5.3%). Breast cases were primary augmentation (36.8%), revision augmentation (21.1%), augmentation mastopexy (15.8%), mastopexy only (15.8%), and other (10.5%). Buttocks cases were gluteal fat grafting (63.6%) and implant insertion (36.4%). Arm cases were all brachioplasty. Median postoperative day was 21 (Interquartile Range [IQR] 11.5, 36). Reasons for presentation included infection (44.5%), dehiscence (16.7%), pain (16.7%), seroma/drainage (11.1%), drain management (5.6%), and hematoma (2.8%). Nearly half received computed tomographic imaging (47.2%). Half of patients were admitted with a median length of stay of 2.5 days (IQR 1, 3). One-third underwent intervention, including implant removal (58.3%), image-guided aspiration (25%), and incision and drainage (16.7%). Patients using tobacco/cannabis were more likely to present with infection (88.9% vs. 25.9%, p=.001) and undergo intervention (66.7% vs. 22.2%, p=.01). There were recurrent emergency department visits among 22.2%. Overall, 44.4% of patients had outpatient follow-up visits for a median of 3 (IQR 2, 4) visits up to a median of 38 (IQR 21.5, 70.5) days after consultation. For the index hospital encounter and any subsequent outpatient/emergency visits, the total median hospital charge was $43,324.96 (IQR $10,728.12, $80,803.18) and median insurance payment was $3,947 (IQR $404.61, $24,516.00). In the setting of operative intervention, median hospital charge and insurance payments were $125,358.70 (IQR $51,065.52, $152,704.70) and $14,863.52 (IQR $3,947, $49,031.13), respectively. Conclusion In this case series, the majority of patients presenting with complaints related to aesthetic surgery were economically disadvantaged and nearly half received surgery abroad. Their surgical complications often directly and significantly cost the state-funded health insurance and strained inpatient and outpatient resources. Nearly a quarter of patients were offered aesthetic surgery despite active smoking, and they were more likely to develop infection and receive invasive treatments. While future analysis should aim to replicate our findings in a larger sample, providers and government agencies should warn their vulnerable patients of these risks.

Short-term air pollution levels and sickle cell disease hospital encounters in South Carolina: A case-crossover analysis

BackgroundSickle cell disease (SCD) is a genetic disorder and symptoms may be sensitive to environmental stressors. Although it has been hypothesized that exposure to outdoor air pollution could trigger acute SCD events, evidence is limited. MethodsWe obtained SCD administrative data on hospital encounters in South Carolina from 2002 to 2019. We estimated outdoor air pollutant (particulate matter<2.5 μm (PM2.5), ozone (O3), and PM2.5 elemental carbon (EC) concentrations at residential zip codes using spatio-temporal models. Using a random bi-directional, fixed-interval case-crossover study design, we investigated the relationship between air pollution exposure over 1-, 3-, 5-, 9-, and14-day periods with SCD hospital encounters. ResultsWe studied 8410 patients with 144,129 hospital encounters. We did not observe associations among all patients with SCD and adults for PM2.5, O3, and EC. We observed positive associations among children for 9- and 14-day EC (OR: 1.05 (95% confidence interval (CI): 1.02, 1.08) and OR: 1.05 (95% CI: 1.02, 1.09), respectively) and 9- and 14-day O3 (OR: 1.04 (95%CI: 1.00, 1.08)) for both. ConclusionsOur findings suggest that short-term (within two-weeks) levels of EC and O3 and may be associated with SCD hospital encounters among children. Two-pollutant model results suggest that EC is more likely responsible for effects on SCD than O3. More research is needed to confirm our findings.

Alpha-1 adrenergic antagonists and the risk of hospitalization or death in non-hospitalized patients with COVID-19: A population-based study.

Alpha-1 receptor antagonists may interfere with IL-6 signaling and could therefore be a potential treatment for COVID-19. However, the effectiveness of these drugs in mitigating the risk of clinical deterioration among non-hospitalized patients with COVID-19 is unknown. The aim of this study is to examine the association between alpha-1 antagonist exposure and the 30-day risk of a hospital encounter or death in nonhospitalized patients with COVID-19. We conducted a population-based cohort study of Ontario residents aged 35 years and older who were eligible for public drug coverage and who had a positive test for SARS-CoV-2 between January 1, 2020, and March 1, 2021. We matched each individual receiving an alpha-1 antagonist at the time of their positive test with two non-exposed individuals using propensity scores. Our outcome was a composite of a hospital admission, emergency department visit, or death, 1 to 30 days following the positive test. We matched 3289 alpha-1 antagonist exposed patients to 6189 unexposed patients. Overall, there was no difference in the 30-day risk of the primary outcome among patients exposed to alpha-1 antagonists at the time of their diagnosis relative to unexposed individuals (28.8% vs. 28.0%; OR 1.00, 95% CI 0.91 to 1.11). In a secondary analysis, individuals exposed to alpha-1 antagonists had a lower risk of death in the 30 days following a COVID diagnosis (OR 0.79; 95% CI 0.66 to 0.93). Alpha-1 antagonists did not mitigate the 30-day risk of clinical deterioration in non-hospitalized patients with COVID-19. Our findings do not support the general repurposing of alpha-1 antagonists as a treatment for such patients, although there may be subgroups of patients in whom further research is warranted.

Socioeconomic factors associated with uptake and satisfaction with a post-hospitalization meals benefit in Medicare Advantage.

Kaiser Permanente Southern California began offering a 4-week supplemental benefit of home-delivered meals to Medicare Advantage members after discharge from a hospitalization for heart failure and other medical conditions in 2021. The purpose of this study is to explore the associations between socioeconomic disadvantage and food insecurity with patient uptake of and satisfaction with the meals. Data for this cross-sectional study were drawn from survey and electronic medical record data for members referred for the meals benefit (n = 6169) and linked to a hospitalization encounter (n = 2254) between January and December 2021. Uptake was assessed using vendor records; measures of socioeconomic status included the neighborhood deprivation index (NDI) and prior receipt of medical financial assistance (MFA) from the health system. Patients were invited to complete an email or phone survey about their satisfaction with the meals and food insecurity. Multivariable log-binomial regression models were used to examine the association between socioeconomic disadvantage and food insecurity with meals uptake and satisfaction. Sixty-two percent of patients referred for the benefit accepted the meals (mean age: 79 ± 9, 59% people of color). While there was no significant relationship between NDI and meals uptake (RR: 0.99, 95% CI: 0.92-1.07, p = 0.77), patients who received prior MFA were more likely to accept the meals (RR: 1.09, 95% CI: 1.02-1.16, p < 0.01). Sixty-nine percent of patients who completed the survey (23% response rate) reported that meals were very or extremely helpful. Patients with food insecurity (29% of survey respondents) were more likely to report that the meals were helpful for their recovery compared to food secure patients (RR: 1.21, 95% CI: 1.09-1.35, p < 0.01). The home-delivered meals appeared to be particularly utilized by and helpful to patients with greater financial strain and/or food insecurity, suggesting that supplemental benefits could be more targeted toward addressing unmet needs of vulnerable adults.

Social determinants of health predict readmission following COVID-19 hospitalization: a health information exchange-based retrospective cohort study.

Since February 2020, over 104 million people in the United States have been diagnosed with SARS-CoV-2 infection, or COVID-19, with over 8.5 million reported in the state of Texas. This study analyzed social determinants of health as predictors for readmission among COVID-19 patients in Southeast Texas, United States. A retrospective cohort study was conducted investigating demographic and clinical risk factors for 30, 60, and 90-day readmission outcomes among adult patients with a COVID-19-associated inpatient hospitalization encounter within a regional health information exchange between February 1, 2020, to December 1, 2022. In this cohort of 91,007 adult patients with a COVID-19-associated hospitalization, over 21% were readmitted to the hospital within 90 days (n = 19,679), and 13% were readmitted within 30 days (n = 11,912). In logistic regression analyses, Hispanic and non-Hispanic Asian patients were less likely to be readmitted within 90 days (adjusted odds ratio [aOR]: 0.8, 95% confidence interval [CI]: 0.7-0.9, and aOR: 0.8, 95% CI: 0.8-0.8), while non-Hispanic Black patients were more likely to be readmitted (aOR: 1.1, 95% CI: 1.0-1.1, p = 0.002), compared to non-Hispanic White patients. Area deprivation index displayed a clear dose-response relationship to readmission: patients living in the most disadvantaged neighborhoods were more likely to be readmitted within 30 (aOR: 1.1, 95% CI: 1.0-1.2), 60 (aOR: 1.1, 95% CI: 1.2-1.2), and 90 days (aOR: 1.2, 95% CI: 1.1-1.2), compared to patients from the least disadvantaged neighborhoods. Our findings demonstrate the lasting impact of COVID-19, especially among members of marginalized communities, and the increasing burden of COVID-19 morbidity on the healthcare system.

Abstract 6477: Modulators of hospital length of stay after intracranial neoplasm excision

Abstract Purpose: Intracranial neoplasms are the leading cause of cancer death among men under 40 years old. A major part of the standard of care is excision of the tumor, but there is a lack of robust large-patient studies of outcomes for these patients. Methods: The Nationwide Inpatient Sample was queried from 2018 to 2020 to identify patients with an intracranial neoplasm. Multivariable linear regression with patient- and hospital-level characteristics as covariates was used to identify factors associated with long hospital stays. Results: From 2018 to 2020, there were 97,795 hospital encounters with a primary diagnosis of an intracranial neoplasm. Of these patients, 64.6% underwent a tumor excision procedure during their hospital visit. The average age of these patients undergoing excision was 57.80.2 years. Most patients were male (58.6%), white (79.1%), private insurance beneficiaries (46.3%), and of the highest income quartile (26.8%). These patients most commonly presented to hospitals in the West (34.9%), with a medium number of beds (36.4%), and presented to rural hospitals (41.7%). The most common locations of these neoplasms were the frontal (29.1%), temporal (21.3%), and parietal (12.1%) lobes. Neoplasms in more than one location in the brain occurred in 4.5% of patients. Multivariable linear regression identified the following factors as significantly associated with longer hospital stays: identifying as Black (beta=2.08; p&amp;lt;0.001), identifying as an Asian or Pacific Islander (beta=1.22; p=0.017), being a Medicaid beneficiary (beta=2.25; p&amp;lt;0.001), and being uninsured (beta=1.63; p&amp;lt;0.001). Having a neoplasm in the cerebral ventricle (beta=4.93; p&amp;lt;0.001), cerebellum (beta=2.81; p&amp;lt;0.001), or brain stem (beta=3.45; p&amp;lt;0.001), and having multiple neoplasms (beta=1.85; p=0.008) were also associated with longer hospital stays. Interestingly, having a parietal (beta=-0.54; p=0.011) or occipital (b=-0.99; p&amp;lt;0.001) lobe neoplasm was associated with shorter hospital stays. Conclusion: Intracranial neoplasms are deadly condition and excision of tumor is a important life-saving treatment option. In this study, we demonstrated that location of neoplasm, race, and insurance status are significant modulators of the length of a hospital stay after surgery. Citation Format: Jayla Hsiung, Kamil Taneja, Lauren Ladehoff, Karan Patel, Eric Toloza. Modulators of hospital length of stay after intracranial neoplasm excision [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6477.

Abstract 6478: Intracranial neoplasms: Disparities in access to care

Abstract Purpose: Excision of intracranial neoplasms is a life-saving procedure. However, there is not much research that has demonstrated how demographic variables interact with a patient’s access to healthcare for intracranial neoplasms. Methods: The Nationwide Inpatient Sample was queried from 2018 to 2020 to identify patients with an intracranial neoplasm. Multivariable logistic regression with patient- and hospital-level characteristics as covariates was used to identify factors associated with receiving an intracranial tumor excision. Results: From 2018 to 2020, there were 97,795 hospital encounters with a primary diagnosis of an intracranial neoplasm. Of these patients, 64.6% underwent a tumor excision procedure during their hospital visit. The average age of all patients with intracranial neoplasm was 58.90.2 years. Most intracranial neoplasm patients were male (59.0%), White (73.8%), Medicare beneficiaries (45.1%), and of the highest income quartile (26.4%). These patients commonly presented to hospitals in the West (35.0%), with a medium number of beds (36.4%), and to rural hospitals (39.1%). The most common locations of these neoplasms were the frontal (18.9%), temporal (12.0%), and parietal (7.5%) lobes. Neoplasms in more than one location in the brain occurred in 5.8% of patients. Multivariable logistic regression identified the following factors as significantly associated with a decreased odds ratio (OR) of receiving an excision surgery: identifying as Black (OR=0.63; p&amp;lt;0.001), Hispanic (OR=0.82; p=0.001), or Asian or Pacific Islander (OR=0.78; p=0.009) and being a Medicaid Beneficiary (OR=0.84; p=0.008). Presenting to a hospital in the South (OR=1.30; p&amp;lt;0.001) or in the West (OR=1.38; p&amp;lt;0.001) were associated with higher chances of having a surgical excision. Conclusion: There are very substantial differences in access to care for brain cancer patients. Race and insurance status are related to a patient’s chance of receiving tumor excision therapy. Citation Format: Jayla Hsiung, Kamil Taneja, Lauren Ladehoff, Karan Patel, Eric Toloza. Intracranial neoplasms: Disparities in access to care [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6478.

Abstract P359: Neighborhood Disinvestment and Racial/Ethnic Disparities in Peripartum Cardiomyopathy in California, From 2004-2019

Introduction: Peripartum cardiomyopathy (PPCM) is a rare life-threatening medical condition presenting as idiopathic heart failure in late pregnancy or during the early postpartum period in otherwise healthy patients. Racial disparities in the rates of morbidity and mortality of PPCM have been extensively documented where higher rates occur in Black patients. There is minimal research examining the relationship between racial/ethnic disparities in PPCM and social determinants of health such as neighborhood social disadvantage. Hypothesis: We hypothesize that neighborhood social disadvantage is associated with PPCM and it contributes to racial/ethnic disparities in PPCM, pre-pregnancy hypertension contributes to disparities, and that the timing of PPCM mostly occurs during the postpartum period. Methods: We used data obtained from the California Department of Health Care Access and Information, which included vital records longitudinally linked with hospital discharge records for mothers and infants up to 9 months postpartum for births in California from 1997-2018. We created and standardized the Neighborhood Deprivation Index (NDI) as a proxy measure for neighborhood social disadvantage and categorized it into quartiles, with quartile 1 indicating the least deprivation and quartile 4 indicating the most deprivation. We examined the distribution of population characteristics for non-Hispanic White, non-Hispanic Black, non-Hispanic Asian and Hispanic births in the sample by PPCM status. We sequentially adjusted multivariable logistic regression models by maternal and clinical characteristics to estimate the association of NDI and race/ethnicity with PPCM using non-Hispanic White as the reference group. We report odds ratios (OR) and 95% confidence intervals (CI) that reflect the total change in odds of PPCM, and calculated the timing of PPCM diagnosis. Results: Our study included 6,970,681 births and 862 (0.012%) PPCM cases. After adjustment, in the NDI regression models, quartile 2 (Q2) through quartile 4 (Q4) had elevated risk for PPCM (Q2: OR 1.2 (CI 1.0-1.5); Q3: OR 1.7 (CI 1.4-2.1); Q4: OR 1.5 (CI 1.2-1.9)). When adjusting for NDI in the race/ethnicity models, the odds of PPCM slightly decreased for each race/ethnicity. After adjusting for pre-pregnancy hypertension in both the NDI and race/ethnicity models, the odds of PPCM slightly decreased for quartile 3 and 4 and in NH Black births. Most PPCM cases (60.4%) were identified during a postpartum hospital encounter. Conclusions: Our results show that neighborhood deprivation and pre-pregnancy hypertension partially explain the racial/ethnic disparities in PPCM. Future research should examine the impact of specific measures of neighborhood deprivation (e.g., access to care, employment levels etc.) on the racial/ethnic disparity in outcomes such as PPCM.

Congenital Tooth Agenesis and Risk of Early-Onset Cancer

There is some evidence that tooth agenesis (congenital absence of 1 or more teeth) is associated with cancer risk, especially carcinomas of the colon and ovaries, but results of previous studies are conflicting, and associations have not yet been evaluated in a population-based setting. To examine the association between tooth agenesis and specific cancer types before 40 years of age. This population-based cohort study used linking data from nationwide registries in Denmark to assess all Danish live-born singletons born from January 1, 1977, to December 31, 2018, and followed up for up to 40 years. Data were analyzed from January through June 2023. Tooth agenesis as documented by the Danish Central Registry of Odontology (Danish municipal pediatric dental care) from January 1, 1988, to December 31, 2018, and from hospital encounters in the Danish National Patient Registry within the entire study period. The primary outcome was first cancer diagnosis before 40 years of age obtained from the Danish Cancer Registry. Associations between tooth agenesis and specific cancers were estimated by Cox proportional hazards regression as hazard ratios (HRs) with 95% CIs. Analyses were split into age groups: younger than 1 year, 1 to younger than 3 years, 3 to younger than 10 years, 10 to younger than 20 years, 20 to younger than 30 years, and 30 to younger than 40 years. Associations with nonsyndromic tooth agenesis were evaluated after exclusion of individuals with known syndromes. Among 2 501 715 included individuals (1 284 292 [51.3%] male), 70 288 (2.8%) had a diagnosis of tooth agenesis (mean [SD] age at diagnosis, 13.2 [4.1] years) and 26 308 (1.1%) had a diagnosis of early-onset cancer within the study period; 778 individuals had co-occurrence of tooth agenesis and cancer. Overall, tooth agenesis was positively associated with several cancer types, including neuroblastoma (age 1 to <3 years; HR, 4.20; 95% CI, 2.24-7.88), nephroblastoma (age 1 to <3 years; HR, 4.59; 95% CI, 2.37-8.91), hepatoblastoma (age 1 to <3 years; HR, 7.10; 95% CI, 2.70-18.68), osteosarcoma (age 10 to <20 years; HR, 2.19; 95% CI, 1.11-4.32), colorectal carcinomas (age 30 to <40 years; HR, 2.81; 95% CI, 1.38-5.71), and carcinomas of bladder (age 20 to <30 years; HR, 3.35; 95% CI, 1.35-8.30). This cohort study found associations between congenital tooth agenesis and several cancer types, from childhood to early adulthood. Further evaluation of these associations is needed to assess possible clinical implications.

Electronic Patient-Reported Symptoms After Ambulatory Cancer Surgery

Complex cancer procedures are now performed in the ambulatory surgery setting. Remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePROs) can identify patients at risk for acute hospital encounters. Defining normal recovery is needed to set patient expectations and optimize clinical team responses to manage evolving problems in real time. To describe the patterns of postoperative recovery among patients undergoing ambulatory cancer surgery with RSM using an ePRO platform-the Recovery Tracker. In this retrospective cohort study, patients who underwent 1 of 5 of the most common procedures (prostatectomy, nephrectomy, mastectomy, hysterectomy, or thyroidectomy) at the Josie Robertson Surgery Center at Memorial Sloan Kettering Cancer Center from September 2016 to June 2022. Patients completed the Recovery Tracker, a brief ePRO platform assessing symptoms for 10 days after surgery. Data were analyzed from September 2022 to May 2023. Symptom severity and interference were estimated by postoperative day and procedure. A total of 12 433 patients were assigned 110 936 surveys. Of these patients, 7874 (63%) were female, and the median (IQR) age at surgery was 57 (47-65) years. The survey response rate was 87% (10 814 patients responding to at least 1 of 10 daily surveys). Among patients who submitted at least 1 survey, the median (IQR) number of surveys submitted was 7 (4-8), and each assessment took a median (IQR) of 1.7 (1.2-2.5) minutes to complete. Symptom burden was modest in this population, with the highest severity on postoperative days 1 to 3. Pain was moderate initially and steadily improved. Fatigue was reported by 6120 patients (57%) but was rarely severe. Maximum pain and fatigue responses (very severe) were reported by 324 of 10 814 patients (3%) and 106 of 10 814 patients (1%), respectively. The maximum pain severity (severe or very severe) was highest after nephrectomy (92 of 332 [28%]), followed by mastectomy with reconstruction (817 of 3322 [25%]) and prostatectomy (744 of 3543 [21%]). Nausea (occasionally, frequently, or almost constantly) was common and experienced on multiple days by 1485 of 9300 patients (16%), but vomiting was less common (139 of 10 812 [1%]). Temperature higher than 38 °C was reported by 740 of 10 812 (7%). Severe or very severe shortness of breath was reported by 125 of 10 813 (1%). Defining detailed postoperative symptom burden through this analysis provides valuable data to inform further implementation and maintenance of RSM programs in surgical oncology patients. These data can enhance patient education, set expectations, and support research to allow iterative improvement of clinical care based on the patient-reported experience after discharge.

Success in Heart Failure? An Investigation of Heart Failure Readmission Rates and Medication Regimen Optimization.

In May 2022, the American College of Cardiology updated their guideline-directed medical therapy for congestive heart failure (CHF) to include four pillars of therapy. These pillars aim to better control patients with heart failure (HF) and reduce the incidence of hospitalization by including an evidence-based beta-blocker, an angiotensin-converting enzyme inhibitor/ angiotensin receptor blocker/angiotensin receptor/ neprilysin inhibitor, a mineralocorticoid receptor antagonist, and newly recommended sodium glucose cotransporter 2-inhibitors. This study at University of Florida Health Central Florida Hospitals reviewed patients who were diagnosed with CHF and recorded if they were readmitted with a HF exacerbation within 30 days of an initial index admission. Patients had data obtained retrospectively using electronic medical records from patient hospital encounters within the study inclusion dates; 7/1/2022-9/30/2022. Hospital readmission rates for patients with CHF, and information on each patient's medication regimen was collected to see if they met medication optimization criteria. A total of 252 patients were evaluated, with 157 meeting the inclusion criteria. Of the patients included, 23 (14.6%) experienced a hospital readmission within 30 days because of acute HF exacerbation or worsening HF. After reviewing medication regimens, 60 patients (38.2%) were receiving treatment with one pillar of therapy, 72 (45.8%) with two pillars of therapy, 12 (7.6%) with three pillars of therapy, and one patient was treated with all four pillars of therapy. In conclusion, this study showed that the recommended pillars of therapy are not being implemented and patients with CHF may benefit from medication optimization.

Impact of Atrial Fibrillation Burden on Health Care Costs and Utilization

BackgroundIntegrating patient-specific cardiac implantable electronic device (CIED)-detected atrial fibrillation (AF) burden with measures of health care cost and utilization allows for an accurate assessment of the AF-related impact on health care use. ObjectivesThe goal of this study was to assess the incremental cost of device-recognized AF vs no AF; compare relative costs of paroxysmal atrial fibrillation (pAF), persistent atrial fibrillation (PeAF), and permanent atrial fibrillation (PermAF) AF; and evaluate rates and sources of health care utilization between cohorts. MethodsUsing the de-identified Optum Clinformatics U.S. claims database (2015-2020) linked with the Medtronic CareLink database, CIED patients were identified who transmitted data ≥6 months postimplantation. Annualized per-patient costs in follow-up were analyzed from insurance claims and adjusted to 2020 U.S. dollars. Costs and rates of health care utilization were compared between patients with no AF and those with device-recognized pAF, PeAF, and PermAF. Analyses were adjusted for geographical region, insurance type, CHA2DS2-VASc score, and implantation year. ResultsOf 21,391 patients (mean age 72.9 ± 10.9 years; 56.3% male) analyzed, 7,798 (36.5%) had device-recognized AF. The incremental annualized increased cost in those with AF was $12,789 ± $161,749 per patient, driven by increased rates of health care encounters, adverse clinical events associated with AF, and AF-specific interventions. Among those with AF, PeAF was associated with the highest cost, driven by increased rates of inpatient and outpatient hospitalization encounters, heart failure hospitalizations, and AF-specific interventions. ConclusionsPresence of device-recognized AF was associated with increased health care cost. Among those with AF, patients with PeAF had the highest health care costs. Mechanisms for cost differentials include both disease-specific consequences and physician-directed interventions.

Defining systolic blood pressure normative values in hospitalized pediatric patients: a single center experience.

Normative blood pressure (BP) values and definition of hypertension (HTN) in children in outpatient setting cannot be reliably used for inpatient therapy initiation. No normative exists to describe HTN in hospitalized pediatric populations. We aimed to study the prevalence of hypertension and produce normative BP values in hospitalized children. Cross sectional observational study of all children hospitalized on acute care floors, ≥2 and <18 years age, at Stanford Children's Hospital, from Jan-01-2014 to Dec-31-2018. Cohort included 7468 hospital encounters with a total of 118,423 automated, oscillometric, BPs measured in the upper extremity during a hospitalization of >24 hours. Overall prevalence of HTN, defined by outpatient guidelines, was 12-48% in boys and 6-39% in girls, stage 1 systolic HTN in 12-38% of boys and 6-31% of girls, stage 2 systolic HTN in 3-10% of boys and 1-8% of girls. Centile curves were derived demonstrating overall higher BP reading for hospitalized patients compared to the outpatient setting. Higher blood pressures are anticipated during hospitalization. Thresholds provided by the centile curves generated in this study may provide the clinician with some guidance on how to manage hospitalized pediatric patients based on clinical circumstances. Hospitalized children have higher blood pressures compared to patients in the ambulatory setting, hence outpatient normative blood pressure values cannot be reliably used for inpatient therapy initiation. No normative exists to describe hypertension in hospitalized pediatric populations. The thresholds provided by the centile curves generated in this study may provide the clinician with some guidance on how to manage hospitalized pediatric patients based on clinical circumstances.

Clinical and molecular determinants of bleeding-related adverse outcomes in high-grade glioma.

Cancer is an independent risk factor for the development of venous thromboembolism (VTE). However, patients with high-grade glioma (HGG) including glioblastoma (GBM) are at a particularly high risk of VTE with an incidence up to 20-30% per year. Patients are often placed on anticoagulation if they are found to have VTE. However, patients with primary brain tumors such as HGG are at increased risk for intracerebral hemorrhage (ICH) even without the administration of anticoagulation. The combination of risk factors for ICH with anticoagulation and HGG complicates decision-making. Currently it is not known which of the direct oral anticoagulants (DOACs) are safest for patients with HGG in terms of adverse bleeding-related outcomes such as ICH. Furthermore, a deeper understanding of the clinical and molecular determinants of bleeding-related adverse outcomes in HGG is not fully characterized. In this retrospective study, we identified and gathered data on 75 consecutive patients with pathology-confirmed HGG with hospital encounters at two academic medical center hospitals in Austin between July 1, 2017 and June 30, 2022. We compared clinical and treatment-related factors among cohorts who had received various forms of anticoagulation or no anticoagulation. Patients who were on rivaroxaban (3/7 (43%)) had a statistically significant association with more bleeding-related adverse events compared to those on apixaban (0/12 (0%)) or enoxaparin (0/5 (0%), p = 0.022) even though the groups were similar in characteristics including total time on the respective anticoagulation. Patients on anticoagulation vs those never on anticoagulation did not differ in terms of their studied demographic and clinical characteristics. Intriguingly, logistic regression analysis revealed that patients Astrocytoma, isocitrate dehydrogenase (IDH) mutant, grade 4 had a significant association with more adverse bleeding-related events even when controlling for other relevant factors (Odds Ratio compared to reference GBM: 49.4, 95% CI: 2.8, 2084.7; p = 0.013). In this study we found that the use of rivaroxaban was associated with more bleeding-related events compared to apixaban and enoxaparin in patients with high-grade glioma. In this study we also found that the diagnosis of astrocytoma, IDH mutant, grade 4 was associated with more bleeding events. However, this is based on a small study and there is a need for larger studies to further evaluate these results.

Aspirin prophylaxis is not associated with increased risk of venous thromboembolism in arthroplasty for femoral neck fractures: a non-inferiority study.

Venous thromboembolism (VTE) is a known complication of hip arthroplasty for femoral neck fractures (FNF) with various prophylactic anticoagulants utilized to decrease risk. The purpose of this study was to assess the efficacy and perioperative outcomes associated with aspirin for VTE prophylaxis following arthroplasty for FNF. Medical records of 1,220 patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) at an urban academic center from 2011 to 2022 were retrospectively reviewed. Patient characteristics and perioperative outcomes, including length of stay (LOS), VTE, 90-day hospital encounters, and discharge disposition, were collected. Outcomes for patients prescribed aspirin (n = 214) were compared to those prescribed non-aspirin VTE prophylaxis (n = 1006) using propensity score matching. Patients who received aspirin had higher rates of THA (36.0 vs 26.7%; p = 0.008). There were no significant risk-adjusted differences in the incidence of VTE (0.5 vs 0.5%, p = 1.000) and 90-day readmissions (10.4 vs 12.3%, p = 0.646) between patients prescribed aspirin and non-aspirin VTE prophylaxis, respectively. Patients prescribed non-aspirin agents had higher rates of non-home discharge (73.9 vs 58.5%; p < 0.001) and longer LOS (143.5 vs 124.9h; p = 0.005). Sub-analysis of patients prescribed aspirin and non-aspirin prophylaxis based on comorbidity scores demonstrated no difference in VTE incidence for low (0.0 vs 1.6%, p = 1.000) and high scores (0.0 vs 0.0%, p = 1.000), respectively. Aspirin is not associated with increased incidence of VTE after HHA or THA for FNF. Aspirin prophylaxis should be considered in hip fracture patients to mitigate bleeding risk, particularly those with low to intermediate VTE risk. Level III, Retrospective study.

Patient factors associated with survival after critical care interhospital transfer

ObjectiveTo identify the factors that predict mortality post-transfer and develop a comprehensive mortality prediction model capable of supporting pre-transfer decision making.Materials and methodsElectronic health record data from the Medical Transport Data Repository of a large health system hospital in Northeast Ohio that consists of a main campus and 11 affiliated medical centers. We retrospectively analyzed patient data from the referring hospital encounter prior to interhospital transfer. All patient data including diagnoses, laboratory results, medication, and medical and social history were analyzed to predict in-hospital mortality post-transfer. We employed a multi-method approach including logistic regression, gradient boosting, and multiple correspondence analysis to identify significant predictors of mortality as well as variables that are clinically useful to inform clinical decision support development. We identified all patients aged 21 and older that underwent critical care transfer in the health system between 2010 and 2017.ResultsWe found that age, laboratory results (albumin, INR, platelets, BUN, leukocyte, hemoglobin, glucose), vital signs (temperature, respirations, pulse, systolic blood pressure, pulse oximetry), and ventilator usage are the most predictive variables of post-interhospital transfer mortality. Using structured data from the EHR we achieved the same performance as APACHE IV within our health system (0.85 vs. 0.85). Lastly, mode of transport alone was not a significant predictor for the general population in any of the outcome models.ConclusionsOur findings provide a foundation for the development of decision support tools to guide transport referrals and identified the need for further inquiry to discern the role of mode of transport to enable future inclusion in decision support approaches. Further inquiry is needed to identify factors that differentiate patients not triaged as time-sensitive transfers but still require helicopter intervention to maintain or improve post-interhospital transfer morbidity and mortality.

Rates of diabetic ketoacidosis with empagliflozin use during hospitalization for acute heart failure.

There is concern that sodium-glucose cotransporter-2 inhibitorsduring hospitalization for acute heart failure (aHF) may precipitate diabetic ketoacidosis (DKA). A retrospective study of all hospitalization encounters for aHF defined by a primary HF International Classification of Diseases (ICD)-10 code in 15 Kaiser Permanente Southern California medical centers hospitalized between January 1, 2021 and August 31, 2023 was performed to describe rates of DKA with empagliflozin use. DKA was defined by the presence of either a DKA ICD-10 code or ketoacidosis lab criteria (bicarbonate <18 mmol/L and urine ketone 1+ or more or elevated serum beta-hydroxybutyrate within 12 h) during hospitalization. Among 21,630 hospital encounters (15,518 patients) for aHF, 1678 (8%) had empagliflozin use. There were 2 (0.1%) probable DKA cases in empagliflozin encounters and 15 (0.1%) in nonexposed encounters. These rates were similar when stratified by diabetes status and ejection fraction. Empagliflozin may be safe during aHF hospitalization.

Derivation and internal validation of the multivariate toxigenic C. difficile diarrhea model and risk score for emergency room and hospitalized patients with diarrhea.

Many factors have been associated with the risk of toxigenic C. difficile diarrhea (TCdD). This study derived and internally validated a multivariate model for estimating the risk of TCdD in patients with diarrhea using readily available clinical factors. A random sample of 3,050 symptomatic emergency department or hospitalized patients undergoing testing for toxigenic C. difficile at a single teaching hospital between 2014 and 2018 was created. Unformed stool samples positive for both glutamate dehydrogenase antigen by enzyme immunoassay and tcdB gene by polymerase chain reaction were classified as TCdD positive. The TCdD Model was created using logistic regression and was modified to the TCdD Risk Score to facilitate its use. 8.1% of patients were TCdD positive. TCdD risk increased with abdominal pain (adjusted odds ratio 1.3; 95% CI, 1.0-1.8), previous C. difficile diarrhea (2.5, 1.1-6.1), and prior antibiotic exposure, especially when sampled in the emergency department (4.2, 2.5-7.0) versus the hospital (1.7, 1.3-2.3). TCdD risk also increased when testing occurred earlier during the hospitalization encounter, when age and white cell count increased concurrently, and with decreased eosinophil count. In internal validation, the TCdD Model had moderate discrimination (optimism-corrected C-statistic 0.65, 0.62-0.68) and good calibration (optimism-corrected Integrated Calibration Index [ICI] 0.017, 0.001-0.022). Performance decreased slightly for the TCdD Risk Score (C-statistic 0.63, 0.62-0.63; ICI 0.038, 0.004-0.038). TCdD risk can be predicted using readily available clinical risk factors with modest accuracy.