Hospital-level Characteristics Research Articles

OUTCOMES OF PATIENTS HOSPITALIZED DUE TO ACUTE EXACERBATION OF COPD AND REQUIRING VENTILATION SUPPORT

TOPIC: Obstructive Lung Diseases TYPE: Original Investigations PURPOSE: Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) with respiratory failure has been associated with higher mortality and morbidities. Implementation of Non-invasive ventilation (NIV) in an early stage of AECOPD with acute respiratory failure has been found to reduce the intubation rate and improve the outcomes. IMV comes in use when the patient cannot tolerate NIV or has worsening respiratory failure despite NIV or has other comorbidities. We hypothesized to see trends and temporal changes in outcomes of AECOPD hospitalizations and factors associated with poor outcomes among those who received ventilation support. METHODS: We extracted data from the Nationwide Inpatient Sample (NIS) for the years 2007-2018 for adult hospitalizations due to AECOPD by using International Classification of Diseases (9th/10th Editions) Clinical Modification diagnosis codes (ICD-9-CM/ICD-10-CM) diagnosis codes and ventilation (IMV and NIV) by procedural codes. Primary objective is to study the trends of discharge disposition (in-hospital mortality and discharge to facilities) and predictors of poor outcomes among those who required ventilation. Cochran Armitage trend test and multivariate survey logistic regression models were used to analyze the data using SAS 9.4 software. RESULTS: We extracted a total of 5,673,467 hospitalizations due to acute exacerbation of COPD from 2007-2018, out of which 455,848 (8.0%) required either IMV or NIV. During the study period, overall, in-hospital mortality has reduced (1.8% in 2007 to 0.4% in 2018; ptrend<0.001) which was largely attributed to decline in in-hospital mortality among those who received NIV (6.3% in 2007 to 2.0% in 2018; ptrend<0.001) and IMV (26.6% in 2007 to 16.7% in 2018; ptrend<0.001). We observed similar declining trends for discharge to facilities. Additionally, among those who received NIV or IMV, age above 65, females (OR 1.1; 95%CI 1.1-1.1; p 0.03), Caucasian (OR 1.5; 95%CI 1.4-1.6; p<0.01), urban-non teaching hospitals (OR 1.2; 95%CI 1.1-1.2; p<0.01), IMV (OR 5.6; 95%CI 5.2-6.0; p<0.01), sepsis (OR 3.5,95%CI 3.3-3.9; p<0.01), pneumonia, CHF, renal failure were associated with higher odds of in-hospital mortality. CONCLUSIONS: Over the years, improved outcomes among AECOPD patients were attributed to significant decline in in-hospital mortality and discharge to facilities among those who received NIV and IMV. Additionally, we also identified several demographic and hospital level characteristics associated with poor outcomes among AECOPD patients requiring ventilatory support. CLINICAL IMPLICATIONS: Our study highlights the outcomes trends of AECOPD patients who required ventilatory support in the last decade. Although outcomes have been improved, still several modifiable factors are associated with higher mortality and morbidity which our study has highlighted. Better risk stratification and strategies are required to further improve the outcomes in these complex patient population. DISCLOSURES: No relevant relationships by Faizan Malik, source=Web Response No relevant relationships by MARIO MEKHAIL, source=Web Response No relevant relationships by Achint Patel, source=Web Response No relevant relationships by Kinjalben Patel, source=Web Response No relevant relationships by Aditi Patil, source=Web Response No relevant relationships by Abdur Raheem, source=Web Response No relevant relationships by Harshil Shah, source=Web Response No relevant relationships by Shiv Shah, source=Web Response No relevant relationships by FARAZ Siddiqui, source=Web Response No relevant relationships by vimala thambi, source=Web Response

Survival outcomes associated with completion of adjuvant oxaliplatin-based chemotherapy for stage III colon cancer: A national population-based study.

The impact of cycle completion rates of oxaliplatin-based adjuvant chemotherapy for stage III colon cancer in real-world practice is unknown. We assessed its impact, and that of treatment modification, on 3-year cancer-specific mortality. Four thousand one hundred and forty-seven patients with pathological stage III colon cancer undergoing major resection from 2014 to 2017 in the English National Health Service were included. Chemotherapy data came from linked national administrative datasets. Competing risk regression analysis for 3-year cancer-specific mortality was performed according to completion of <6, 6-11, or 12 5-fluoropyrimidine and oxaliplatin (FOLFOX) cycles, or <4, 4-7, or 8 capecitabine and oxaliplatin (CAPOX) cycles, adjusted for patient, tumour and hospital-level characteristics. Median age was 64 years. Thirty-two per cent of patients had at least one comorbidity. Forty-two per cent of patients had T4 disease, and 40% had N2 disease. Compared to completion of 12 FOLFOX cycles, cancer-specific mortality was higher in patients completing <6cycles [subdistribution hazard ratios (sHR) 2.17; 95% CI 1.56-3.03] or 6-11 cycles (sHR 1.40; 95% CI 1.09-1.78) (P < .001). Compared to completion of 8 CAPOX cycles, cancer-specific mortality was higher in patients completing <4cycles (sHR 2.02; 95% CI 1.53-2.67) or 4-7cycles (sHR 1.63; 95% CI 1.27-2.10) (P < .001). Dose reduction and early oxaliplatin discontinuation did not impact mortality in patients completing all cycles. Completion of all cycles of chemotherapy was associated with improved cancer-specific survival in real-world practice. Poor prognostic factors may have affected findings, however, patients completing <50% of cycles had poor outcomes. Clinicians may wish to facilitate completion with treatment modification in those able to tolerate it.

Alternative Approaches to Ensuring Adequate Nurse Staffing: The Effect of State Legislation on Hospital Nurse Staffing.

The objective of this study was to addresses the basic question of whether alternative legislative approaches are effective in encouraging hospitals to increase nurse staffing. Using 16 years of nationally representative hospital-level data from the American Hospital Association (AHA) annual survey, we employed a difference-in-difference design to compare changes in productive hours per patient day for registered nurses (RNs), licensed practical/vocational nurses (LPNs), and nursing assistive personnel (NAP) in the state that mandated staffing ratios, states that legislated staffing committees, and states that legislated public reporting, to changes in states that did not implement any nurse staffing legislation before and after the legislation was implemented. We constructed multivariate linear regression models to assess the effects with hospital and year fixed effects, controlling for hospital-level characteristics and state-level factors. Compared with states with no legislation, the state that legislated minimum staffing ratios had an 0.996 (P<0.01) increase in RN hours per patient day and 0.224 (P<0.01) increase in NAP hours after the legislation was implemented, but no statistically significant changes in RN or NAP hours were found in states that legislated a staffing committee or public reporting. The staffing committee approach had a negative effect on LPN hours (difference-in-difference=-0.076, P<0.01), while the public reporting approach had a positive effect on LPN hours (difference-in-difference=0.115, P<0.01). There was no statistically significant effect of staffing mandate on LPN hours. When we included California in the comparison, our model suggests that neither the staffing committee nor the public reporting approach alone are effective in increasing hospital RN staffing, although the public reporting approach appeared to have a positive effect on LPN staffing. When we excluded California form the model, public reporting also had a positive effect on RN staffing. Future research should examine patient outcomes associated with these policies, as well as potential cost savings for hospitals from reduced nurse turnover rates.

Equity And The Uneven Distribution Of Federal COVID-19 Relief Funds To US Hospitals.

People of color, immigrants, and those relying on the safety net have experienced a disproportionate share of the death and disease resulting from COVID-19 in the US. At the same time, Congress delegated great power to the Trump administration to distribute $178billion in funding to health care providers. We studied the relationship between the relief received by 2,709 hospitals and community- and hospital-level characteristics. Funding through early February 2021 averaged $25.7million per hospital. Our findings offer a mixed picture. Some correlates of real-world need, including serving a community with a very high share of Black residents or having a very high ratio of Medicaid revenue to beds, were associated with meaningfully increased funding. Other correlates of need-including serving a very high share of Hispanic residents or a Medically Underserved Area-were associated with decreased funding or no difference in funding. Our findings emphasize that funding formulas reflect consequential political judgments. In future allocations, the relationship between need and aid should be strengthened by de-emphasizing historical net patient revenue in favor of a broader set of community and hospital characteristics.

Reality of Accomplishing Surgery within 24 Hours for Complete Cervical Spinal Cord Injury: Clinical Practices and Safety.

Substantial clinical data support an association between superior neurological outcomes and early (within 24 h) surgical decompression for those with traumatic cervical spinal cord injury (SCI). Despite this, much discussion persists around feasibility and safety of this time threshold, particularly for those with a complete cervical SCI. This study aims to assess clinical practices and the safety profile of early surgery across a large sample of North American trauma centers. Data were derived from the Trauma Quality Improvement Program database from 2010-2016. Adult patients with a complete cervical SCI (American Spinal Injury Association [ASIA] A) who underwent surgery were included. Patients were stratified into those receiving surgery at or before 24 h and those receiving delayed intervention. Risk-adjusted variability in surgical timing across trauma centers was investigated using mixed-effects regression. In-hospital adverse events including death, major complications, and immobility-related complications were compared between groups after propensity score matching. There were 2862 patients from 353 North American trauma centers included; 1760 (61.5%) underwent surgery within 24 h. Case-mix and hospital-level characteristics explained only 6% of the variability in surgical timing both between centers and within centers. No significant differences in adverse events were identified between groups. These findings suggest a relatively large proportion of patients are not receiving surgery within the recommended time frame, despite apparent safety. Moreover, patient and hospital-level characteristics explain little of the variability in time-to-surgery. Further knowledge translation is needed to increase the proportion of patients in whom surgery is performed before the 24-h threshold so patients might reach their greatest potential for neurological recovery.

Between-hospital variability in organ donation after resuscitation from out-of-hospital cardiac arrest

IntroductionSurvival and recovery after out-of-hospital cardiac arrest (OHCA) varies between hospitals, with better outcomes associated with high-volume and specialty care. We evaluated if there is a similar relationship with organ donation after OHCA. MethodsWe studied a cohort of adults resuscitated from OHCA from 2010 to 2018, treated at one of 112 hospitals served by a regional organ procurement organization (OPO). We obtained hospital-level characteristics from Centers for Medicare and Medicaid Services and Health Resources and Services Administration and obtained patients’ clinical information from the OPO health record. We excluded patients with no potential to donate on initial referral. Our primary exposure was treatment at a high-volume hospital (defined > 500 eligible cases during the study period) and our primary outcomes were suitability to donate after full medical evaluation, successful organ procurement and organ transplantation. We used mixed effects models to quantify between-hospital variability in the primary outcomes. ResultsOverall, 9792 patients were included and 796 (8%) were organ donors. We identified significant between-hospital variation in odds of donation (median odds ratio 1.64 [95% CI 1.42–2.02]). Hospital volume explained the greatest proportion of variability. High volume centers had a higher proportion of referrals with potential to donate (16.9 vs 12.2%), actual donation (10.3 vs 6.2%), and successful transplantation (9.4 vs 5.7%). Overall, 2032/7763 (26%) of recovered transplantable organs in this region were procured from OHCA patients. ConclusionHigh volume centers are more likely to refer and procure transplantable organs from patients with non-survivable OHCA.

B-PO04-201 IMPACT OF PSORIATIC ARTHRITIS ON ATRIAL FIBRILLATION HOSPITALIZATIONS: ANALYSIS OF NATIONAL INPATIENT SAMPLE 2007-2014

Patients with inflammatory arthropathies have an increased risk of arrhythmias, which has been linked to the direct effect of inflammation on the myocardium's electrical stability. We aim to assess the impact of co-existing psoriatic arthritis (PsA) on outcomes in patients with atrial fibrillation (AF). We conducted a retrospective analysis of adult (age >/= 18) discharges from the National Inpatient Sample database between 2007 and 2014. The ICD-9-CM codes were used to identify those with AF and PsA. The primary outcome was inpatient mortality. Weighted multivariate logistic regression analysis was used to adjust for several patient-level and hospital-level characteristics. A total of 28419475 hospitalizations with AF were identified. A diagnosis of PsA was present in 21990 hospitalizations. Hospitalizations for AF with PsA had lower in-patient mortality [3.21 % vs 4.92%, adjusted odd's ratio (aOR) 0.76, 95% CI 0.64-0.90, p 0.001], compared to those without PsA. There were no differences in odds of ischemic stroke [aOR 0.88, p 0.177], hemorrhagic stroke [aOR 0.73, p 0.126], implantable cardioverter defibrillator implantation [aOR 0.83, p 0.318], acute kidney injury [aOR 1, p 0.946] and vasopressor requirement [aOR 0.89, p 0.536], however odds of undergoing pacemaker implantation [aOR 0.71, p 0.008] and cardiac arrest [aOR 0.61, p 0.006] were lower. Our analysis showed a decreased mortality in hospitalizations with AF and PsA compared to those without PsA. This could be due to the protective effect of the anti-inflammatory medications used in PsA or under coding of PsA in hospitalized patients, leading to skewed results.

B-PO01-058 CATHETER ABLATION VS SURGICAL ABLATION IN ATRIAL FIBRILLATION: ANALYSIS OF NATIONAL INPATIENT SAMPLE, 2004-2018

Atrial fibrillation (AF) is the most common arrhythmia in United states. Surgical or catheter ablation are used in selected patients to reduce the morbidity or mortality. To compare clinical outcomes of catheter ablation and surgical ablation in AF. We conducted a retrospective analysis of adult discharges from the National Inpatient Sample (NIS) between 2004 and 2018. International Disease Classification codes were used to identify AF hospitalizations, who underwent catheter ablation or surgical ablation. Prevalence estimates were weighted using NIS-provided discharge-level weights to reflect national estimates. Weighted multivariable logistic regression was used to compare the impact of catheter ablation vs surgical ablation on in-hospital mortality and several other clinical outcomes. These models were adjusted for several patient-level and hospital-level characteristics. A total of 5975241 weighted catheter ablations and catheter ablations were identified from 2004-2018. After adjustment of variables, surgical ablation was associated with higher rates of stroke, use of pressors, invasive mechanical ventilation, acute kidney injury, acute kidney injury requiring dialysis, all-cause mortality, cardiogenic shock, mechanical circulatory support, gastrostomy, tracheostomy, cardiac arrest, length of stay and inflation-adjusted cost (Table 1). Our study showed significantly better in-hospital outcomes with catheter ablation, when compared to surgical ablation in AF patients.

Recidivism following childhood maltreatment necessitating inpatient care in the United States

IntroductionNon-accidental trauma (NAT) is one of the common causes of injury in children in the United States (US). Abuse and maltreatment affect 2 per 100,000 children annually and may go unrecognized. The aim of this study to quantify the recidivistic nature of NAT in the US pediatric population. MethodsThe National Readmissions Database (2007–2015) was queried for pediatric (≤18y) trauma patients. Children presenting for non-accidental trauma were further identified. Data was obtained on demographic, clinical, and hospital-level characteristics. Body regions with an Abbreviated Injury Scale (AIS) greater than three were further identified. Multivariable logistic regression analysis (adjusting for age, gender, insurance status, year, Injury Severity Score [ISS], hospital region, and mechanism of injury) was utilized to determine factors influencing unintentional and intentional (assault) non-accidental traumatic injuries. ResultsNAT represents 1.6% (n = 4,634/286,508) of all pediatric trauma. The median age of presentation was <1y [IQR:0–3] with a male predominance (56.2%). Median ISS was 9 [IQR:2–16]. 87.5% of incidents represented assault (intentional). The most commonly affected body region was the head and neck (32.8%), followed by the extremities (11.4%) and soft tissue trauma or burns (6.3%). Penetrating trauma accounted for 18% of these injuries. 3.2% were readmitted to the hospital for a recurrent episode. 85.5% presented to the hospital for their initial evaluation. Mortality rates were 3.8% for those re-admitted to the hospital. The most common perpetrators were other specified persons known to the family, followed by fathers and mothers. ConclusionAlthough uncommon, recidivism, after an initial episode of NAT, can have devastating consequences. The majority of the perpetrators of abuse are individuals known to the patient or family. Health policy aimed towards developing preventative strategies is needed to facilitate early recognition and tackle abuse in children. Level of EvidenceIII. Type of EvidenceCase Control Study.

Racial Disparities in Acute Coronary Syndrome Management Within a Universal Healthcare Context: Insights From the AMI-OPTIMA Trial

BackgroundAlthough prior studies have demonstrated racial disparities regarding acute coronary syndrome (ACS) care within private or mixed healthcare systems, few researchers have explored such disparities within universal healthcare systems. We aimed to evaluate the quality and outcomes of in-hospital ACS management for White patients vs patients of colour, within a universal healthcare context. MethodsWe performed a post hoc analysis of the Acute Myocardial Infarction - Knowledge Translation to Optimize Adherence to Evidence-Based Therapy study, a cluster-randomized trial evaluating a knowledge-translation intervention at 24 hospitals in Quebec, Canada (years: 2009 and 2012). The primary endpoint was coronary catheterization. The secondary endpoints included in-hospital mortality, percutaneous and surgical coronary revascularization, major bleeding, total stroke, and discharge prescription of evidence-based medical therapy. ResultsOf 3444 included patients, 2738 were White, and 706 were people of colour. The mean age was 68.2 years (33.3% women) among White patients and 69.5 years (36.0% women) among patients of colour. Patients of colour were less likely to undergo in-hospital coronary catheterization than were White patients (74.5% vs 80.3%, P = 0.001). This difference was attenuated after adjusting for patient-level characteristics (odds ratio 0.89; 95% confidence interval 0.73-1.09), and it was eliminated after adjusting for hospital-level characteristics (odds ratio 1.04; 95% confidence interval 0.73-1.49). ConclusionsRacial disparity in coronary catheterization for ACS persists within a universal healthcare context. Patients’ comorbidities and hospital-level factors may be partially responsible for this inequality. Future research on cardiovascular healthcare in patients with diverse racial/ethnic backgrounds in universal healthcare systems is needed to remediate racial inequality in ACS management.

The Impact of China's Zero Markup Drug Policy on Hospitalization Expenses for Inpatients in Tertiary Public Hospitals: Evidence Based on Quantile Difference-in-Difference Models.

Objectives: The aim of this study was to determine the impact of the Zero Markup drug (ZMD) policy on hospitalization expenses for inpatients in tertiary Chinese hospitals. Methods: Using the administrative data from hospital electronic health records (EHRs) between 2015 and 2017, we implemented the quantile difference-in-differences (QDID) estimators to evaluate the impact of the ZMD policy on hospitalization expenses while controlling for patient-level and hospital-level characteristics. Results: According to the QDID models, the introduction of ZMD policy significantly induced lower drug costs for all inpatients especially at the 50th (-USD 507.84 (SE = USD 90.91), 75th (-USD 844.77 (SE = USD 149.70), and 90th (-USD 1400.00 (SE = USD 209.97)) percentiles of the overall distributions. However, the total hospitalization, diagnostic, treatment, material and services expenses for inpatients were significantly higher for the treated group than the control group. This tendency was more pronounced for inpatients in tertiary hospitals with lower expenses (in the 10th, 25th and 50th percentiles). Conclusion: The implementation of ZMD policy alone may not be enough to change the medical service providers’ profit-driven behavior. The targeted supervision of hospital costs by the Chinese health administration department should be strengthened to avoid unreasonable hospital charges.

The impact of regionality and hospital status on mortality associated with non-accidental trauma

IntroductionNon-accidental trauma (NAT) affects 2 per 100,000 children annually in the US and may go unrecognized. The aim of this study to quantify the burden of NAT and to evaluate regional variations in mortality. MethodsThe Kids Inpatient Database (2000–2012) was queried for pediatric patients presenting with a diagnosis of NAT. Data was obtained on demographic, clinical and hospital-level characteristics. Primary outcome measure was mortality. Multivariable logistic regression models for age, sex, race/ethnicity, insurance status, income quartile, hospital volume, region (Northeast, South, West and Midwest), teaching status, and injury severity scores. ResultsNAT represented 1.92% (n = 15,999) of all trauma patients. Mortality rates were 3.98% for patients presenting with NAT. African American children had a higher likelihood of mortality compared to White children (OR[95%CI]:1.35[1.03–1.79]), however, this effect was not statistically significant for patients being treated at designated children's hospitals (OR[95%CI]:1.23(0.78–1.95) and urban facilities (OR[95%CI]:1.30[0.99–1.72]). Statistically significant regional variations in mortality, lost significance for patients treated at designated children's hospitals (p > 0.05). ConclusionNAT has devastating consequences and is associated with a high mortality rate. Treatment at designated children's hospitals results in the loss of variation in mortality, resulting in diminished disparities and improved outcomes. These findings align with current trends towards the “regionalization of pediatric health care” and reflects the value of regional transfer centers that are.

Laboratory-identified vancomycin-resistant enterococci bacteremia incidence: A standardized infection ratio prediction model.

We analyzed 2017 healthcare facility-onset (HO) vancomycin-resistant Enterococcus (VRE) bacteremia data to identify hospital-level factors that were significant predictors of HO-VRE using the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) multidrug-resistant organism and Clostridioides difficile reporting module. A risk-adjusted model that can be used to calculate the number of predicted HO-VRE bacteremia events in a facility was developed, thus enabling the calculation of VRE standardized infection ratios (SIRs). Acute-care hospitals reporting at least 1 month of 2017 VRE bacteremia data were included in the analysis. Various hospital-level characteristics were assessed to develop a best-fit model and subsequently derive the 2018 national and state SIRs. In 2017, 470 facilities in 35 states participated in VRE bacteremia surveillance. Inpatient VRE community-onset prevalence rate, average length of patient stay, outpatient VRE community-onset prevalence rate, and presence of an oncology unit were all significantly associated (all 95% likelihood ratio confidence limits excluded the nominal value of zero) with HO-VRE bacteremia. The 2018 national SIR was 1.01 (95% CI, 0.93-1.09) with 577 HO bacteremia events reported. The creation of an SIR enables national-, state-, and facility-level monitoring of VRE bacteremia while controlling for individual hospital-level factors. Hospitals can compare their VRE burden to a national benchmark to help them determine the effectiveness of infection prevention efforts over time.

Obesity paradox in catheter ablation of atrial fibrillation: analysis of national inpatient sample 2016-2018

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Obesity is a common cardiovascular risk factor and have been associated with favorable outcomes in congestive heart failure, coronary artery disease and atrial fibrillation (Afib), the so-called obesity paradox. Purpose To study the phenomenon of obesity paradox for in-hospital and procedural outcomes in catheter ablation of Afib hospitalizations. Methods We queried January 2016 to December 2018 National Inpatient Sample (NIS) to identify adult (≥18 yrs) hospitalizations with a primary diagnosis of Afib. Patients with appropriate ICD-10 PCS codes for catheter ablation were identified. Obese patients were compared with non-obese patients. We used the Chi-square tests to evaluate the differences between binary or categorical variables, and Student’s t-tests for continuous variables. Multivariate logistic regression was used in outcomes analysis to adjust for potential hospital and patient-level confounders. Results We identified 53,524 weighted catheter ablation of Afib procedural hospitalizations across three years. Of which, 13,335 (25%) of them were associated with obesity. The obese hospitalizations were associated with younger age (mean age 64.0 vs 69.3 yrs; P &amp;lt; 0.01), higher persistent Afib (46.6% vs 37.5%; P &amp;lt; 0.01), higher comorbidity burden (% of &amp;gt;3 Elixhauser comorbidity score 96.8% vs 72.6%; P &amp;lt; 0.01) and had more OSA (43.6% vs 14.7%; P &amp;lt; 0.01). After adjusting for patient and hospital-level characteristics, we observed statistically significant decrease in odds of in-hospital mortality in obese Afib patients undergoing catheter ablation compared to non-obese [Odds Ratio (OR): 0.000004; P &amp;lt; 0.01]. We also observed the obese group had statistically significant association with longer LOS [4.1 vs 3.8 days; P &amp;lt; 0.01], lower total hospitalization charges [US$ 144,882 vs 157,412; P &amp;lt; 0.01] and increased odds of post-operative respiratory failure [OR: 1.97 (1.03 – 3.7); P = 0.04] compared to non-obese group. Conclusion In this large retrospective study of catheter ablation of Afib hospitalizations, higher BMI and obesity was associated with decreased in-hospital mortality consistent with the obesity paradox phenomenon. However, it was associated with longer LOS. The vascular complications and other procedural outcomes except respiratory failure were comparable between both groups. Further prospective studies are necessary to verify our study findings.

Real-world survival outcomes associated with completion of adjuvant chemotherapy for stage III colon cancer.

3596 Background: The optimal duration of adjuvant combination chemotherapy administered to patients with stage III colon cancer is debated. Our study assessed the effect of completed chemotherapy cycles on 3-year colon cancer-specific mortality, as well as the effect of dose reduction and early discontinuation of oxaliplatin in patients with 100% completion, within a real-world population. Methods: 4,147 patients undergoing major resection between 01 June 2014 and 30 April 2017 with pathological stage III colon cancer in the English National Health Service were identified. Chemotherapy data were obtained from linked administrative hospital records and a national chemotherapy dataset. Patients were stratified according to completion of &lt; 50% ( &lt; 6 FOLFOX cycles or &lt; 4 CAPOX cycles), 50-92% (6-11 FOLFOX cycles or 4-7 CAPOX cycles) or 100% of cycles (12 FOLFOX cycles or 8 CAPOX cycles). Competing-risk regression analysis for 3-year colon cancer-specific death was performed with adjustment for patient, tumour and hospital-level characteristics to estimate subdistribution hazard ratios (sHR) as a measure of relative risk. Results: Patients included within our study were less fit and had increased rates of high-risk disease (T4 and/or N2 pathological staging) compared to the IDEA study. For FOLFOX, the 3-year cumulative incidence of colon cancer-specific death in patients completing 100% of cycles was 15.1% (95% CI, 12.8% to 17.6%), 18.2% (95% CI, 15.3% to 21.3%) for 50-92% of cycles and 26.4% (95% CI, 20.6% to 32.5%) for &lt; 50% of cycles. For CAPOX, this was 12.0% (95% CI, 10.2% to 14.0%) for 100% completion of cycles, 18.2% (95% CI, 15.6% to 21.0%) for 50-92% of cycles, and 19.8% (95% CI, 15.8% to 24.1%) for &lt; 50% cycles. Compared to 100% completion of FOLFOX cycles, colon cancer-specific death was higher in patients recorded as completing &lt; 50% (sHR 2.17; 95% CI, 1.56 to 3.03; P = &lt; 0.001) and 50-92% of FOLFOX cycles (sHR 1.40; 95% CI, 1.09 to 1.78; P = 0.007). Compared to 100% completion of CAPOX cycles, colon cancer-specific death was higher in patients recorded as completing &lt; 50% (sHR 2.02; 95% CI 1.53 to 2.67; P&lt; 0.001) and 50-92% of CAPOX cycles (sHR 1.63; 95% CI 1.27 to 2.10; P&lt; 0.001). Dose reduction and early discontinuation of oxaliplatin did not have a statistically significant effect on mortality. Conclusions: Patients within the real world setting were more likely to have poor prognostic factors. Those who completed adjuvant chemotherapy for stage III colon cancer had improved survival rates regardless of dose reduction or early discontinuation of oxaliplatin.

Temporal Trends and Factors Associated With Cardiac Rehabilitation Participation Among Medicare Beneficiaries With Heart Failure

ObjectivesThe purpose of this study was to assess temporal trends and factors associated with cardiac rehabilitation (CR) enrollment and participation among Medicare beneficiaries after the 2014 Medicare coverage expansion. BackgroundCR improves exercise capacity, quality of life, and clinical outcomes in heart failure (HF) with reduced ejection fraction (HFrEF). In 2014, Medicare coverage for CR was expanded to include chronic HFrEF. MethodsAmong Medicare beneficiaries from quarter (Q) 1 2014 to Q2 2016, 11,696 patients from 14,258 hospitalizations with primary discharge diagnosis of HF were identified. Patients with HF with preserved ejection fraction were excluded. Quarterly CR participation rates among hospitalized HF patients within 6 months of discharge were identified through outpatient administrative claims. The predictors of CR participation were assessed with the use of a multivariable logistic regression model that included patient- and hospital-level characteristics. A secondary analysis to assess participation rates of CR after outpatient encounters for HF was performed. ResultsOverall, only 611 (4.3%) and 349 (2.2%) eligible patients participated CR after primary hospitalization or outpatient visit for HF, respectively. There was a modest, statistically significant increase in CR participation after HF admissions (2.8% in Q1 2014; 5.0% in Q2 2016; p < 0.001) without significant increase after outpatient visits for HF (2.6% to 3.8%; p = 0.21). Younger age, male sex, nonblack race, previous cardiovascular procedures, and hospitalization at hospitals with available CR facilities were all independently associated with CR participation. ConclusionsCR participation among eligible Medicare beneficiaries with HFrEF was low with minimal increase since 2014 Medicare coverage decision. Sex, race, and institution-dependent variables were independent predictors of CR participation.

Obesity paradox in HFrEF hospitalizations: analysis of national inpatient sample 2016-2018

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Obesity is a common and known risk factor for many cardiovascular diseases. Prior studies on chronic systolic heart failure have demonstrated that obesity is inversely associated with mortality, the so-called obesity paradox. Purpose To study the phenomenon of obesity paradox in HFrEF hospitalizations Methods We queried January 2016 to December 2018 National Inpatient Sample (NIS) to identify adult (≥18 yrs) hospitalizations with a primary diagnosis of HFrEF. Patients with an associated diagnosis of obesity and higher BMI were also identified based on appropriate ICD-10 CM codes. We used the Chi-square test to evaluate the differences between binary or categorical variables, and Student’s t-test for continuous variables. Multivariate logistic regression was used in outcomes analysis to adjust for potential hospital and patient-level confounders. Results We identified 639,944 weighted HFrEF hospitalizations across three years. Of which, 130,949 (20.4%) of them were associated with obesity. HFrEF with obesity hospitalizations were associated with younger age (mean age 62.0 vs 70.7 yrs; P &amp;lt; 0.01), lesser CAD (55% vs 61%; P &amp;lt; 0.01), higher rate of comorbidity (% of &amp;gt;3 Elixhauser comorbidity score 99.2% vs 94.1%; P &amp;lt; 0.01) and higher Medicaid primary payer (18.2% vs 12.7%, P &amp;lt; 0.01). After adjusting for patient and hospital-level characteristics, we observe statistically significant difference in odds of in-hospital mortality when HFrEF with obesity hospitalizations was compared to HFrEF without obesity [Odds Ratio (OR): 1.1 (0.8 – 1.5); P = 0.52]. We observed statistically significant association with increased LOS [6.0 vs 5.3 days; P &amp;lt; 0.01], increased total hospitalization charges [US$ 61524 vs 55677; P &amp;lt; 0.01] and decreased coronary catheterizations [OR: 0.7 (0.5 – 0.9); P = 0.01] in HFrEF with obesity group compared to HFrEF without obesity. Conclusion In this retrospective cohort of hospitalized patients with HFrEF, higher BMI and obesity was not associated with in-hospital mortality. However, it was associated with longer LOS and higher total hospitalization charges. HFrEF with obesity hospitalizations are associated with lesser left coronary catheterizations. This may be explained by lesser burden of CAD in this patient population.

Burden of dementia in atrial fibrillation hospitalizations- analysis of national inpatient sample 2016-2018

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation is a common disorder in the elderly population and a known risk factor for stroke and dementia. Purpose To study the burden of dementia in Afib hospitalizations and identify the predictors of in-hospital mortality in Afib with dementia hospitalizations. Methods We queried January 2016 to December 2018 National Inpatient Sample (NIS) to identify adult (≥18 yrs) hospitalizations with a primary diagnosis of Afib. Hospitalizations of Afib with dementia was compared with Afib without dementia. We used the Chi-square test for differences between categorical variables, and Student’s t-test for continuous variables. Multivariate logistic regression was used in outcomes analysis to adjust for potential hospital and patient-level confounders. Results We identified 1,236,540 weighted Afib hospitalizations across three years. Of which, 79,405 (6.4%) of them were associated with dementia. Afib with dementia hospitalizations were associated with older age (mean age 83.2 vs 70.0 yrs; P &amp;lt; 0.01), higher rate of chronic Afib (15.3% vs 7.5%; P &amp;lt; 0.01), higher rate of comorbidity (% of &amp;gt;3 Elixhauser comorbidity score 91.8% vs 83.6%; P &amp;lt; 0.01). After adjusting for patient and hospital-level characteristics, we observed that Afib with dementia hospitalizations was associated with higher odds of in-hospital mortality compared to Afib without dementia [Odds Ratio (OR): 1.6 (1.4 – 1.9); P &amp;lt; 0.01]. We also observed statistically significant association with increased LOS [4.7 vs 3.2 days; P &amp;lt; 0.01], repeated falls [OR: 2.8 (2.5 – 3.1); P &amp;lt; 0.01] and protein calorie malnutrition [OR: 1.9 (1.7 – 2.0); P &amp;lt; 0.01] in Afib with dementia group. Conclusion Afib with dementia hospitalizations are not only associated with higher mortality, but they are also associated with higher repeated fall rates, and skilled nursing facility discharge dispositions. Co-morbidities like hypertension, CKD, obesity, HFrEF, HFpEF, OSA are associated with higher in-hospital mortality. Our study findings emphasize the burden of dementia in Afib hospitalizations and the need for prevention of poor outcomes in this population.

Patient, hospital and country-level risk factors of all-cause mortality among patients with chronic heart failure: Prospective international cohort study.

Although many studies have described patient-level risk factors for outcomes in heart failure (HF), health care structural determinants remain largely unexplored. This research reports patient-, hospital- and country-level characteristics associated with 1-year all-cause mortality among patients with chronic HF, and investigates geographic and hospital variation in mortality. We included 9,277 patients with chronic HF enrolled between May 2011 and November 2017 in the prospective cohort study European Society of Cardiology Heart Failure Long Term registry across 142 hospitals, located in 22 countries. Mean age of the selected outpatients was 65 years (sd 13.2) and 28% were female. The all-cause 1-year mortality rate per 100 person-years was 7.1 (95% confidence interval (CI) 6.6-7.7), and varied between countries (median 6.8, IQR 5.6-11.2) and hospitals (median 7.8, IQR 5.2-12.4). Mortality was associated with age (incidence rate ratio 1.03, 95% CI 1.02-1.04), diabetes mellitus (1.37, 1.15-1.63), peripheral artery disease (1.56, 1.27-1.92), New York Heart Association class III/IV (1.91, 1.60-2.30), treatment with angiotensin-converting enzyme inhibitor and angiotensin receptor antagonists (0.71, 0.57-0.87) and HF clinic (0.64, 0.46-0.89). No other hospital-level characteristics, and no country-level healthcare characteristics were associated with 1-year mortality, with case-mix standardised variance between countries being very low (1.83e-06) and higher for hospitals (0.372). All-cause mortality at 1 year among outpatients with chronic HF varies between countries and hospitals, and is associated with patient characteristics and the availability of hospital HF clinics. After full adjustment for clinical, hospital and country variables, between-country variance was negligible while between-hospital variance was evident.

Predictors of Success in the Bundled Payments for Care Improvement Program.

Hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program were incented to reduce Medicare payments for episodes of care. To identify factors that influenced whether or not hospitals were able to save in the BPCI program, how the cost of different services changed to produce those savings, and if "savers" had lower or decreased quality of care. Retrospective cohort study. BPCI-participating hospitals. We designated hospitals that met the program goal of decreasing costs by at least 2% from baseline in average Medicare payments per 90-day episode as "savers." We used regression models to determine condition-level, patient-level, hospital-level, and market-level characteristics associated with savings. In total, 421 hospitals participated in BPCI, resulting in 2974 hospital-condition combinations. Major joint replacement of the lower extremity had the highest proportion of savers (77.6%, average change in payments -$2235) and complex non-cervical spinal fusion had the lowest (22.2%, average change +$8106). Medical conditions had a higher proportion of savers than surgical conditions (11% more likely to save, P=0.001). Conditions that were mostly urgent/emergent had a higher proportion of savers than conditions that were mostly elective (6% more likely to save, P=0.007). Having higher than median costs at baseline was associated with saving (OR: 3.02, P<0.001). Hospitals with more complex patients were less likely to save (OR: 0.77, P=0.003). Savings occurred across both inpatient and post-acute care, and there were no decrements in clinical care associated with being a saver. Certain conditions may be more amenable than others to saving under bundled payments, and hospitals with high costs at baseline may perform well under programs which use hospitals' own baseline costs to set targets. Findings may have implications for the BPCI-Advanced program and for policymakers seeking to use payment models to drive improvements in care.