ICD9-CM Codes Research Articles

107. Effect of osteoporosis and bisphosphonate on reoperations in adult spinal deformity

BACKGROUND CONTEXT Adult spinal deformity is a complex pathology that often requires challenging surgical intervention for treatment. In patients with osteoporosis, there may be increased risk of complications and reoperations. Our study aimed to evaluate the effect of treating osteoporosis patients with bisphosphonate preoperatively on future reoperations. PURPOSE Investigate the effect of preoperative bisphosphonate on osteoporosis patients undergoing corrective surgery for adult spinal deformity. STUDY DESIGN/SETTING Retrospective review of the PearlDiver database between the years 2008-2015. PATIENT SAMPLE This study included 2,842 adult spinal deformity patients. OUTCOME MEASURES Ninety-day complications, reoperations. METHODS Adult spinal deformity patients undergoing a fusion were isolated using ICD-9 CM and CPT codes in the PearlDiver database between the years 2008-2015. Patients were stratified based on diagnosis of osteoporosis and whether there was a filled prescription for bisphosphonate 6 months prior to surgery. ASD patients with osteoporosis and bisphosphonate use who underwent corrective intervention were compared with age- and sex-matched cohorts of osteoporotic and nonosteoporotic controls with no bisphosphonate prescriptions. Means comparison tests compared differences in demographics, comorbidities, 90-day complications, and 2Y reoperation rates. Logistic regression analysis assessed the odds of complication and reoperations controlling for age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was set p<0.05. RESULTS A total of 2,842 operative adult spinal deformity patients were isolated. Four hundred and six patients had osteoporosis and bisphosphonate use, 807 osteoporosis with no bisphosphonate use, and 1,629 non-osteoporosis patients. At baseline, osteoporosis patients had higher rates of obesity, diabetes, hyperlipidemia, and peripheral vascular disease compared to osteoporotic bisphosphonate cohort. There were no differences in 90-day complication rates or 2Y reoperations rates between osteoporosis bisphosphonate users and osteoporosis controls (p>0.05). Compared to nonosteoporotic patients, osteoporosis patients with bisphosphonate use trended toward lower rates of revisions at 1Y (5% vs 7%) and 2Y (7% vs 8%, both p>0.05). CONCLUSIONS In a matched cohort, osteoporosis patients treated preoperatively with bisphosphonates trended towards lower rates of revisions two years postoperatively compared to nonosteoporotic controls. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Adult spinal deformity is a complex pathology that often requires challenging surgical intervention for treatment. In patients with osteoporosis, there may be increased risk of complications and reoperations. Our study aimed to evaluate the effect of treating osteoporosis patients with bisphosphonate preoperatively on future reoperations. Investigate the effect of preoperative bisphosphonate on osteoporosis patients undergoing corrective surgery for adult spinal deformity. Retrospective review of the PearlDiver database between the years 2008-2015. This study included 2,842 adult spinal deformity patients. Ninety-day complications, reoperations. Adult spinal deformity patients undergoing a fusion were isolated using ICD-9 CM and CPT codes in the PearlDiver database between the years 2008-2015. Patients were stratified based on diagnosis of osteoporosis and whether there was a filled prescription for bisphosphonate 6 months prior to surgery. ASD patients with osteoporosis and bisphosphonate use who underwent corrective intervention were compared with age- and sex-matched cohorts of osteoporotic and nonosteoporotic controls with no bisphosphonate prescriptions. Means comparison tests compared differences in demographics, comorbidities, 90-day complications, and 2Y reoperation rates. Logistic regression analysis assessed the odds of complication and reoperations controlling for age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was set p<0.05. A total of 2,842 operative adult spinal deformity patients were isolated. Four hundred and six patients had osteoporosis and bisphosphonate use, 807 osteoporosis with no bisphosphonate use, and 1,629 non-osteoporosis patients. At baseline, osteoporosis patients had higher rates of obesity, diabetes, hyperlipidemia, and peripheral vascular disease compared to osteoporotic bisphosphonate cohort. There were no differences in 90-day complication rates or 2Y reoperations rates between osteoporosis bisphosphonate users and osteoporosis controls (p>0.05). Compared to nonosteoporotic patients, osteoporosis patients with bisphosphonate use trended toward lower rates of revisions at 1Y (5% vs 7%) and 2Y (7% vs 8%, both p>0.05). In a matched cohort, osteoporosis patients treated preoperatively with bisphosphonates trended towards lower rates of revisions two years postoperatively compared to nonosteoporotic controls.

Post-stroke epilepsy and mortality: an observational study on healthcare administrative database

Abstract Background Post-stroke epilepsy (PSE) has been associated with hospitalization and increased mortality risk. So far, evidence on PSE and mortality risk is lacking. Therefore, this study aimed to evaluate the association between PSE and mortality in different type of stroke. Methods A retrospective observational study was conducted using healthcare administrative databases of Lombardy, a northern Italian region (16.4% of the Italian population). Patients aged 40 years or older admitted to the hospital between 1/1/2004 and 31/12/2008 with diagnosis of hemorrhagic (HS)- or ischemic (IS)- stroke were included. Diagnosis of seizure/epilepsy was identified by using discharge ICD9-CM codes, exemption code or use of antiepileptic drugs. This date was considered the index date. For each stroke cohort case of PSE was matched with 2 non post-stroke epileptic (PNS) individuals. Demographic and clinical characteristics were compared between PSE and PSN among the stroke cohorts. Cox proportional regression model was used to estimate the hazard ratio (HRs) and 95% confidence intervals (95%CI) of mortality. Results In the observed period, 13,749 of patients (4,583 PSE Vs 9,166 PSN) had IS and 4,875 (1,625 PSE Vs 3,250 PNS) had HS. Individuals were ≥75-year-old with no difference among cohorts (p value &amp;gt;0.9). Similarly, no differences were observed for gender (p = 1.00) and Charlson'comorbidity index (p = 1.00). Early seizure occurred in 15% of ischemic cohort and 20% of hemorrhagic one. Differences in antithrombotic drug use were observed among PSE and PSN in IS (p = 0.009) and HS cohort (p = 0.03). In ischemic cohort PSE was positively associated with increased mortality risk (HRadj: 1.67; 95%CI: 1.57-1.79), whereas no significant result was observed in hemorrhagic cohort (1.06; 0.94-1.20). Conclusions This study demonstrated a twofold increased risk of mortality in IS cohort. Further studies need to deeply characterize possible association between PSE and mortality in HS individuals. Key messages Occurrence of seizure/epilepsy in ischemic post-stroke patients represents a risk factor for morality. New studies need to clarify the contrasting result observed for hemorrhagic PSE patients.

Hiatal Hernia Associated with Higher Odds of Dysplasia in Patients with Barrett’s Esophagus

Patients with Barrett's esophagus (BE) are more likely to have associated hiatal hernia (HH) compared to the general population. Studies show that HH are typically longer and wider in patients with BE. To determine whether patients with HH have associated increased odds of coexistence of BE by examining inpatient prevalence, as well as determining other inpatient outcomes. This was a case-control study using the NIS 2016, the largest public inpatient database in the USA. All patients with ICD10CM codes for BE were included. None were excluded. The primary outcome was determining the association between BE and HH in hospitalized patients, stratified by grade of dysplasia. Secondary outcomes included measuring use of endoscopic ablation in patients with BE and HH compared to patients with BE and no HH, determining the degree of association between HH and esophagitis in patients with or without BE, as well as the association between esophagitis and dysplasia in patients with BE and HH. A total of 118,750 patients with BE were identified, of which 24,030 had associated HH. Adjusted odds of having associated BE in patients with HH was 10.9 (p < 0.01) compared to patients without HH. Patients with HH also displayed significantly higher odds of both low-grade dysplasia (aOR 34.5, p < 0.01) and high-grade dysplasia (aOR 14.7, p < 0.01). For secondary outcomes, the odds of undergoing ablation for BE was higher 4.77 (p < 0.01) in patients with HH. Patients with HH have significantly higher odds of having associated BE, regardless of the level of dysplasia. Furthermore, the odds of undergoing ablation are much higher, likely reflecting higher odds of dysplasia. This highlights the importance of BE in patients with HH, and potentially consider these patients as higher risk.

Rate and Modifiable Predictors of 30-Day Readmission in Patients with Acute Respiratory Distress Syndrome in the United States.

BackgroundThe 30-day readmission rates are being used as a quality measure by Centers for Medicare and Medicaid Services (CMS) for specific medical and surgical conditions. Acute respiratory distress syndrome (ARDS) is one of the important causes of morbidity and mortality in the United States (US). The characteristics and predictors of 30-day readmission in ARDS patients in the US are not widely known, which we have depicted in our study.ObjectiveThe aim of this study is to identify 30-day readmission rates, characteristics, and predictors of ARDS patients using the largest publicly available nationwide database.MethodsWe used the National Readmission Database from the year 2013 to extract the patients with ARDS by primary discharge diagnosis with ICD9-CM codes. All-cause unplanned 30-day readmission rates were calculated for patients admitted between January and November 2013. The independent predictors for unplanned 30-day readmission were identified by survey logistic regression.ResultsAfter excluding elective readmission, the all-cause unplanned 30-day readmission rate for ARDS patients was 18%. Index admissions readmitted within 30-day had a significantly higher baseline burden of comorbidities with a Charlson Comorbidity Index (CCI) ≥1 as compared to those who were not readmitted within 30 days. In multivariate regression analysis, several predictors associated with 30-day readmission were self-pay/no charge/other (OR 1.19, 95%CI: 1.02-1.38; p = 0.02), higher-income class (OR 0.86, 95%CI:0.79-0.99; p = 0.03), private insurance (OR 0.81, 95%CI:0.67-0.94; p = 0.01), and teaching metropolitan hospital (OR 0.72, 95%CI:0.61-0.94; p = 0.01).ConclusionThe unplanned 30-day readmission rates are higher in ARDS patients in the US. Several modifiable factors such as insurance, socioeconomic status, and hospital type are associated with 30-day readmission among ARDS patients.

Portal Hypertension and Chronic Kidney Disease Significantly Increase the Risk of Early Unplanned Readmissions in GAVE- Related Admissions.

Gastric antral vascular ectasia (GAVE) is an uncommon cause of non-variceal upper gastrointestinal bleeding that is characterized by dilation of blood vessels in the antrum of the stomach. Various co-morbidities are associated with the development of GAVE, but the impact of co-morbidities on unplanned GAVE readmissions is unclear. The aim of this study was to assess the national incidence, 30-day mortality rate, and 30-day readmissions related to GAVE. Secondary outcomes were evaluation of predictors of early readmission, hospital length of stay (LOS) and total hospitalization charges. Using the 2016 National Readmission Database, we analyzed discharges for GAVE. ICD-10 CM codes were utilized to identify associated comorbidities and inpatient procedures during the index admission. 30-day readmissions were identified for GAVE. Secondary measures of outcomes including LOS and hospitalization charges were also calculated. Risk factors for early readmission were also evaluated using multivariate analysis to adjust for confounders. A total of 18,375 index admissions for GAVE were identified. 20.49% (n=3,720) of the discharged patients were readmitted within 30 days. 30-day mortality of GAVE-related admissions was 1.82% (n=335). Early readmissions accounted for 20,157 hospital days along with $189 million in hospitalization costs. Multivariate analysis revealed that the presence of portal hypertension (OR 1.63; 95% CI 1.37-1.93; p=0.0001) and chronic kidney disease (CKD) (OR 1.62, 95% CI 1.44-1.82; p<0.0001) significantly increased the odds of early readmission. Our analysis demonstrates that the overall 30-day mortality rate of GAVE-related admissions is relatively low, but the 30-day readmission rate is significantly high. Patients with comorbid CKD and portal hypertension have a significantly higher risk of readmission. Further studies are required to determine if therapeutic interventions such as argon plasma coagulation or radiofrequency ablation during the index admission may prevent readmissions in these specific subgroups.

2270-PUB: Advanced Diabetes Does Not Necessarily Increase Risk of Liver Disease

Objective: The association between uncontrolled diabetes mellitus (DM) and liver disease (LD) has been established. The impact of different etiologies of LD on specific DM complications (Cx) is not well known. The aim of this study is to determine if the frequency of DM complications are related to specific LD etiologies. Methods: This is a cross-sectional study of the 2016 National Inpatient Sample database. Adult patients with type 2 DM were studied. ICD-10 CM codes were used to identify DM complications and different LD etiologies. Univariate analyses and multivariate logistic regressions were performed. Results: 1,538,604 patients met inclusion criteria. The prevalence of DM complications was 26.9%. Based on multivariate analysis results (Table 1), kidney Cx were associated with increased viral hepatitis. Ophthalmic Cx were preferentially associated with an increased prevalence of hepatitis B but not C. Skin and circulatory Cx were associated with less reported in all LD, while neurological Cx were associated more with reported LD. Conclusion: Among inpatients, the prevalence of DM Cx differ by LD, with more significant differences noted for patients with Hepatitis etiologies. Our analysis is limited with retrospective nature and should be supported with future prospective studies. Disclosure M.A. Minhem: None. A. Nakshabandi: None. M. Cerasale: None.

1078 Sleep Problems In Posttraumatic Stress Disorder (PTSD) In A Nationally Representative Us Sample Before And After Controlling For Comorbid Depression: Results From A Nationally Representative US Sample

Abstract Introduction The impact of psychiatric comorbidities on sleep disturbances in PTSD have been studied in the National Comorbidity Survey (NCS)(Leskin GA, 2002) and the NCS-replication (Lauterbach D, 2011) studies. We examined sleep problems in PTSD before and after controlling for comorbid depressive disease, in the National Ambulatory Medical Care Survey(NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) which use a multi-stage probability design to collect nationally representative data on health care visits. Methods We examined patient visits(1995-2015) from NAMCS/NHAMCS with a PTSD diagnosis (ICD-9-CM 309.81). Both NAMCS/NHAMCS allow ≥3 reasons for visit(RFV) and ≥3 physician-assigned diagnoses (using ICD9-CM codes). The following variables were created: ‘Insomnia’: ICD9-CM codes 307.41,307.42,780.51,RFV 11351; ‘Sleep Disturbance’(SD): ICD-9CM codes 780.5, 780.50, 780.59; ‘Nightmares’: ICD9-CM code 307.4, RFV 11353; Obstructive sleep apnea (OSA): ICD-CM codes 327.23,780.57, RFV 11355, checklist; and ‘Depression’: ICD9-CM codes 296.2, 296.3, 296.82, 311, 296.20-296.36, 300.4. Results There were an estimated 37,262,245±3,203,047 (unweighted count or UWC=3,995; 66.4%±1.8% female;.mean±age: 40.39 ± 0.56 years; ‘Depression’ was comorbid with 37.7%±1.5% cases) PTSD patients visits. All sleep variables accounted for 11.2%±1.2% (UWC=303) of PTSD visits with their individual frequencies as follows: ‘Insomnia’6.5%±1.1%(UWC=153); ‘Nightmares’: 1.9%±0.4%(UWC=74); ‘SD’: 2.0%±0.3%(UWC=67); OSA: 1.3%±0.3%(UWC=27). Logistic regression analysis using PTSD versus all other patient visits as dependent variable revealed the following sleep predictors of PTSD after controlling for age and sex and: (i) before controlling for ‘Depression’: ‘Insomnia’: OR=7.16, (95%CI 4.78-10.73); ‘SD’: OR=4.43(95%CI 2.55-7.71); ‘Nightmares’:OR=104.29 (95%CI56.65-192.02); ‘OSA’: OR=1.71(95%CI 0.94-3.12); and (ii) after controlling for ‘Depression’: ‘Insomnia’: OR=2.88 (95%CI 1.87-4.42); ‘SD’: OR=2.84 (95%CI 1.73-4.67); and ‘Nightmares’: OR=58.33(95%CI 26.39-128.94); and ‘OSA’: OR=2.02(95%CI 1.14-3.57). Conclusion In a nationally representative sample, the association of PTSD with insomnia, sleep disturbance and nightmares remained significant, albeit decreased, after controlling for the confounding effect of comorbid depression; however the association of PTSD with OSA emerged only after the effect of depression was controlled for. Support None

Rising incidence of clostridium difficile infection and associated clinical outcomes in hospitalized cancer patients: A national perspective.

e19095 Background: Cancer patients are more prone to Clostridium difficile infection (CDI). Several factors such as increased exposure to antibiotics (either in the form of prophylaxis or treatment), being on chemotherapy, and frequent exposure to healthcare settings are responsible for this. Rate of CDI in these patients ranges from 10-20%. Here, we performed a retrospective analysis using the national inpatient sample to study the trend and to see whether CDI leads to poor outcomes in these patients. Methods: We have used National Inpatient Sample database from the year 2009 to 2015 to identify hospitalized adult patients with cancer using ICD-9 CM codes. Similarly, We also identified patients with concurrent CDI amongst all cancer patients. Our primary aims were to study the trend of CDI and associated outcomes in from of mortality, cost of hospitalization and length of stay. Incidence of CDI per 10,000 discharges in those patients over the study period was assessed. Outcomes related to CDI in cancer patients were compared with those without CDI. Categorical and continuous variables were compared between matched cohorts using Chi-square and Student’s t-test, respectively. Statistical significance level was set at &lt; 0.05. All analyses were performed with the use of SAS (version 9.4). Results: Total of 6,035,966 cancer patients was identified over the study period. Out of which, 57,167 (0.9%) had concurrent CDI. Age, sex and race were comparable in both the groups. Incidence of CDI increased from 89 cases to 101 cases per 10,000 cancer patients (p-trend: &lt; 0.05). Inpatient mortality was significantly higher in cancer patients with CDI compared to without CDI(12.1% vs 4.7%, p &lt; 0.0001). Cost of hospitalization was almost 3 times higher ($36,243 vs $12,910, p &lt; 0.0001).Median length of stay was almost four-fold longer (16 days vs 4 days, p &lt; 0.0001). Patients with Medicare and Medicaid had higher percentages of CDI cases while patients with private insurance had lower percentages. Conclusions: Incidence of CDI in cancer patients is on the rise. CDI lead to higher mortality, cost of hospitalization, and length of stay in cancer patients. Preventive strategies in form of judicious use of antibiotics and prompt identification with treatment may help with reducing mortality and associated healthcare burden.

Abstract 201: Sex Differences in Management and Outcomes in Young Adults With Myocardial Infarction

Objectives: Sex differences are known to exist in the management ofolder patients presenting with myocardial infarction (MI). Whether inpatient MI management, outcomes and readmissions differ by sex in young adults is not known. Methods: Nationwide Readmissions Database (NRD) was queried for hospitalizations with MI in adults between 18 and 50 years of age from October 2015 and November 2016 using ICD-10 CM codes. Hospitalizations with discharges in December were excluded as 30-day follow-up for these could not be completed in NRD. Logistic regression analysis was used to estimate the association between gender and percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), coronary angiography, non-invasive testing, death and 30-day readmissions. ST-elevation MI (STEMI) subset was similarly analyzed. Results: Of 33,981 hospitalizations, 29% were females. Mean age was 43 years. STEMI constituted 13,177 hospitalizations with 22% females. As compared with men, women were more likely to have peripheral vascular disease (6% vs 4%), chronic pulmonary disease (17% vs 10%), diabetes mellitus (36% vs 28%); and less likely to have a prior history of MI (10% vs 12%). Women were less likely to undergo noninvasive testing (10% vs 11 %, p=0.002) and were revascularized less often than men with PCI (45% vs 56%, p&lt;0.0001) and CABG (6% vs 7%, p&lt;0.0001). Women underwent PCI less often in STEMI as well (72% vs. 76%, p&lt;0.0001). Inpatient mortality and 30-day readmissions were higher in women overall (1.9% vs 1.6%, p=0.04) and (14% vs 9%, p&lt;0.0001); as well as in STEMI: (4% vs 3%, p&lt;0.0001) and (12% vs 8%, p&lt;0.0001). In adjusted analysis (Figure 1: A, B), women were less likely to undergo non-invasive testing or revascularization in the overall cohort; and were less likely to undergo PCI in the STEMI cohort. Additionally, women had higher odds of 30-day readmissions overall, while the odds of inpatient mortality were higher only in STEMI subset. Conclusion: In a large MI cohort, young women were less likely to undergo ischemic workup and be revascularized, and had higher odds of 30-day readmissions. Women had higher odds of mortality in STEMI

ASSESSING THE WEEKEND EFFECT IN THE SURGICAL MANAGEMENT OF OVARIAN TORSION

The weekend effect refers to a phenomenon of disparate care among patients admitted on weekends compared to patients admitted on weekdays1. This effect has been documented in the literature in a variety of medical and surgical subspecialties including gynecology2. Ovarian torsion is a gynecologic emergency occurring when the adnexa rotates around its suspensory ligaments estimated to account for 3% of emergency room presentations for acute abdominal pain in women3. The management of ovarian torsion involves urgent surgical correction of torsion with removal of ovarian pathology or ovary as indicated. Prompt diagnosis and treatment are required to preserve future fertility and decrease morbidity. The purpose of this study was to evaluate whether weekend presentation of ovarian torsion impacts timing to surgical management. We utilized data from the 2002-2014 abstracts of the Nationwide Inpatient Sample, identifying surgical cases of ovarian torsion using diagnosis and procedure ICD-9CM codes. Time to surgery was evaluated as the time from admission to surgery, quantified in days with the primary predictor of interest being day of admission (weekend versus weekday). Multivariable log-linear regression models were fit to assess the outcomes of same day surgery and risk of oophorectomy as the treatment for torsion. Models were adjusted by patient demographics and hospital risk factors. The risk of oophorectomy model was further adjusted by time to surgery categorized as same-day, one day, or two or more days. Measures of association were expressed in adjusted risk ratios (aRR) and 95% confidence intervals (CI). From 2002 to 2014, a nationwide cohort of 122,816 inpatient hospital admissions for surgical management of ovarian torsion were analyzed. Of the surgical ovarian torsion cases, 20.2% were admitted on the weekend with a 60% same day surgery rate compared to 69% of those admitted on weekdays. In adjusted analysis, patients admitted on the weekend were 14% less likely to undergo same day surgical management of ovarian torsion (RR=0.86, 95% CI: 0.84, 0.88) compared to those admitted on weekdays (Table 1). Non-Hispanic Black, Hispanic, Medicare, Medicaid, and lower income quartile patients were similarly less likely to undergo same day surgical management (Table 1). Weekend admission was not associated with increased risks of oophorectomy as management strategy of torsion, however ovarian torsion cases who waited more than one day were at 5% higher risk of oophorectomy compared to those with same-day management (Table 2). While the weekend effect is associated with lower likelihood of same-day management of ovarian torsion, weekend admission is not associated with increased risk of oophorectomy in the surgical management of ovarian torsion. Our data suggests that timely management of these cases is more strongly associated with fertility preservation. Socioeconomic disparities exist in both timely management as well as fertility preserving surgical treatment.

Inpatient epidemiology and economic burden of granulomatosis with polyangiitis: a 10-year study of the national inpatient sample.

To characterize inpatient epidemiology and economic burden of granulomatosis with polyangiitis (GPA). Patients with GPA were identified from the Nationwide Inpatient Sample (NIS), the largest inpatient database in the USA consisting of over 4000 non-federal acute care hospitals, using the ICD-9 CM code. A cohort of comparators without GPA was also constructed from the same database. Data on demographics, procedures, length of stay, mortality, morbidity and total hospitalization charges were extracted. All analysed data were extracted from the database for the years 2005-2014. The inpatient prevalence of GPA was 32.6 cases per 100000 admissions. GPA itself (38.3%), pneumonia (13.7%) and sepsis (8.4%) were the most common reasons for admission. After adjusting for potential confounders, the all-cause mortality adjusted odds ratio (aOR) of patients with GPA was significantly higher than that of patients without GPA (aOR 1.20; 95% CI: 1.41, 1.61). This was also true for several morbidities, including acute kidney injury, multi-organ failure, shock and need for intensive care unit admission. Hospitalizations of patients with GPA were associated with higher cost as demonstrated by an adjusted additional mean of $5125 (95% CI: $4719, $5531) for total hospital cost and an adjusted additional mean of $16841 (95% CI: $15280, $18403) for total hospitalization charges when compared with patients without GPA. Inpatient prevalence of GPA was higher than what would be expected from prevalence in the general population. Hospitalizations of patients with GPA were associated with higher morbidity, mortality and cost.

Impact of liver disease on oral anticoagulant prescription and major adverse events in patients with atrial fibrillation: analysis from a population-based cohort study.

Data on the impact of liver disease (LD) in patients with atrial fibrillation (AF) and the role of oral anticoagulant (OAC) drugs for stroke prevention are limited. A retrospective observational population-based cohort study on the administrative health databases of Lombardy region Italy. All AF patients ≥40 years admitted to hospital from 2000 to 2018 were considered. Atrial fibrillation and LD diagnosis were established using ICD9-CM codes. Use of OAC was determined with Anatomical Therapeutic Chemical codes. Primary study outcomes were stroke, major bleeding, and all-cause death. Among 393 507 AF patients, 16 168 (4.1%) had concomitant LD. Liver disease AF patients were significantly less treated with OAC. Concomitant LD was associated with an increased risk in all the study outcomes [hazard ratio (HR): 1.18, 95% confidence interval (CI): 1.11-1.25 for stroke; HR: 1.57, 95% CI: 1.47-1.66 for major bleeding; HR: 1.41, 95% CI: 1.39-1.44 for all-cause death]. Use of OAC in patients with AF and LD resulted in a reduction in stroke (HR: 0.80, 95% CI: 0.70-0.92), major bleeding (HR: 0.86, 95% CI: 0.74-0.99), and all-cause death (HR: 0.77, 95% CI: 0.73-0.80), with similar results according to subgroups. A net clinical benefit (NCB) analysis suggested a positive benefit/risk ratio in using OAC in AF patients with LD (NCB: 0.408, 95% CI: 0.375-0.472). In AF patients, concomitant LD carries a significantly higher risk for all clinical outcomes. Use of OAC in AF patients with LD was associated with a significant favourablebenefit/risk ratio, even in high-risk patient subgroups.

121 The Opioid Dependence Paradox in Among Patients with Burn Injury

Abstract Introduction The opioid epidemic has contributed significantly to the healthcare economic burden nationwide. Methods Using the 2016 National Readmission Database, patients were included if they had a principal diagnosis of burn injury. Opioid dependence was identified using appropriate ICD-10 CM codes. The primary outcome was 30-day all-cause readmission. Secondary outcomes were in-hospital and calendar-year mortality, resource utilization, and most common reasons for admission and readmission. Confounders were adjusted for using multivariate regression analysis. Results 22,348 patients were included, 597 of whom were opioid dependent. Opioid dependent patients were more likely to be older (43 years, range: 38.6–47.2 years) and male (70.8%) compared with patients without opioid dependence. Opioid dependence was associated with higher 30-day readmission rates (adjusted odds ratio (aOR): 1.93, 95% confidence interval (CI):1.39–2.68, p-value: &amp;lt; 0.01), longer mean length of stay (adjusted mean difference (aMD): 5.46 days, CI:2.63–8.29, p-value: &amp;lt; 0.01). and higher total hospitalization charges (aMD: $50,050, CI:$5,941-$94,960, p-value: 0.03) and costs (aMD: $14,889, CI:$3,658-$26,119, p-value: 0.01). However, opioid dependence was associated with lower in-hospital (aOR: 0.23, CI:0.06–0.85, p-value: 0.03) and calendar-year (aOR: 0.47, CI:0.22–0.99, p-value: 0.04) mortality. The most common reasons for both initial admission and readmission are presented in Table 1. Conclusions Opioid dependence is associated with lower in-hospital and calendar-year mortality, but higher rates of readmission, longer mean length of stay and higher hospital charges among patients with burn injuries. Applicability of Research to Practice Despite increased resource utilization for patients with opioid dependence, mortality was decreased in this population. Further research is needed to elucidate this paradox.

22 16-year State-wide Population-based Analysis of Burn and Inhalation Injury – Demographics, Injury Characteristics, Management, and One-year Outcomes

Abstract Introduction Estimates on frequency and outcomes of burn or inhalation injury in the United States are limited since reported databases are confined to specific phases of care, included facilities, length of follow-up, facility/provider/patient identification and/or lack of longitudinal tracking. A population-based database addresses these issues. Methods We queried a statewide mandated-reporting database for the years from 2000 through 2015 at the time of injury using a set of ICD9-CM codes for second degree or deeper burns, inhalation injury, and chemical and electrical burns. Burn total body surface area percentage by anatomical region was assigned as appropriate using modified and age-stratified Lund and Browder charts. Records for each patient were extracted out to one year pre- and post-injury, as available. Provider and facility burn volume and survival was stratified into quartiles. We applied the Committee on Trauma/American Burn Association referral criteria to the index presentation. Kaplan-Meier curves were generated to 1-year post injury for testing combinations of burn percent total body surface area of 20% and inhalation injury for age ranges &amp;lt; 15, 15 - 60, and &amp;gt;60 years. Regression models were developed to model the probabilities of in-patient, 90-day, and 365-day mortality and readmission. Results 56,712 patients were included. Overall, 22% of patients meeting referral criteria were never seen at a burn center within 1-year post-injury. The greatest positive predictors of in-patient mortality were facility case volume and burn percent total body surface area. The greatest negative predictors were high provider burn case volume (for highest quartile, adjusted odds ratio 0.08, 95% confidence intervals 0.06 – 0.12). The highest risk of unscheduled 30-day readmission was associated with index presentation to a non-burn care facility (p &amp;lt; 0.001). For all groups, the first 100 days had the greatest mortality rate, the most severe being among patients of age greater than 60 with &amp;gt;20% burn percent total body surface area and inhalation injury, with a 40% survival rate. Conclusions This study is the first to be able to simultaneously evaluate in-patient, post-discharge, and facility-based parameters for outcomes. A significant number of patients are not accounted with current databases. Applicability of Research to Practice A population-based approach with longitudinal tracking allows for greater realization of the outcomes of all patients following burn injury. Existing association-supported or government databases fail to account for a significant portion of burn victims, motivating further evaluation of burn care efforts.

National prevalence, trends and outcomes of takotsubo syndrome in hospitalizations with prior history of mediastinal/intrathoracic cancer and radiation therapy

BackgroundRadiation therapy (RT) for cancers in thoracic/mediastinal region has been linked with heart damage following years of radiation exposure. However, prevalence of takotsubo syndrome (TTS) in patients with prior intrathoracic/mediastinal malignancies treated with RT has never been analyzed on a large scale. MethodsWe identified adult hospitalizations with prior mediastinal/intrathoracic cancer and RT and TTS using ICD-9 CM codes and the National Inpatient Sample (2007–2014) after excluding current admissions for chemotherapy. We then assessed the prevalence, odds, trends and in-hospital outcomes of TTS-related admissions in patients with vs. without prior intrathoracic cancer and RT. ResultsWe identified a total of 5,991,314 hospitalizations with prior intrathoracic/mediastinal malignancies and RT (~73 yrs., 85.2% female), of which 7663 (0.13%, 128 per 100,000) were diagnosed with TTS (~74 yrs., 95.8% females, 88.1% white). Higher odds and rising trends in TTS per 100,000 hospitalizations (from 31 to 241) were seen among patients with prior intrathoracic malignancies and RT as compared to those without (from 19 to 104) (ptrend < 0.001). All-cause in-hospital mortality (4.6% vs 2.8%; OR 1.45; 95%CI 1.29–1.63, p < 0.001), cardiogenic shock (4.3% vs 0.2%), cardiac arrest (3.1% vs 0.9%), arrhythmia (34.3% vs 24.6%), stroke (3.6% vs 2.8%), respiratory failure (14.5% vs 4.6%), and median length of stay and hospital charges were significantly higher in the TTS cohort. ConclusionsThis study showed higher odds and increasing trends in TTS-related admissions with worse in-hospital outcomes among patients with prior intrathoracic/mediastinal cancer and RT, irrespective of the time interval from cancer diagnosis or RT to TTS occurrence.

Impact of fragmentation on rehospitalization after bariatric surgery

The care of patients who have undergone bariatric surgery is complex and requires a multidisciplinary approach. As such, these patients may be prone to fragmentation of care and differences in healthcare outcomes. We aimed to (1) determine the incidence of fragmentation among patients after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), (2) identify risk factors for readmission, and (3) ascertain whether care fragmentation affects outcomes. This is a retrospective cohort study using the National Readmission Database 2016. Patients were included if they had primary bariatric surgery during the index hospitalization using appropriate ICD-10 CM codes. Fragmentation of care was defined as a readmission to a different hospital within 90days of the index admission. Primary outcome was incidence of fragmentation. Secondary outcomes were impact of fragmentation on (1) in-hospital mortality; (2) resource utilization (length of stay (LOS), total hospitalization charges and costs, in-hospital upper endoscopy (EGD), and abdominal imaging studies; and (3) independent predictors of readmission using multivariate regression analysis. A total of 136,536 subjects were included. 90-day readmission demonstrated a prevalence of fragmentation of 21.1%. Type of surgery was an independent predictor of fragmentation, with RYGB leading to increased risk (OR 1.90 [95% confidence interval (CI) 1.61, 2.25]; p-value < 0.0001). RYGB was associated with higher adjusted mean hospitalization costs, which was not explained by increased EGD (OR 0.95, CI 0.68, 1.32) or abdominal imaging (OR 0.52, CI 0.25, 1.06). No differences were found in mortality or LOS. Over 20% of patients following primary bariatric surgery have inpatient readmissions that are fragmented, driven by patients who have undergone RYGB surgery. This may be due to the complexity of this procedure and the need for a multispecialty approach. Additional efforts targeting fragmentation should be made to better coordinate the management of these complex patients and reduce healthcare costs.

Abstract TP309: Utilization of IV-rtPA and Endovascular Therapy Use on Off-Hours vs. On-Hours: An Age Group Comparison

Introduction: Previous studies have yielded inconsistent results on whether weekend admission impacts the utilization of EVT and IV-rtPA. There is limited data available of whether age groups difference affects on use of IV-rtPA and EVT admitted during the off-hours. Our study aimed to investigate whether admission during the off-hours has any effect on the EVT &amp; IV-rtPA utilization and is distributed uniformly across all age groups? Method: All adults admitted to US hospitals from 2005-2015 with a primary diagnosis AIS (n=4,520,516) were identified from the Nationwide Inpatient Sample using ICD-9 CM codes. Discharge weights were used to generate national estimates. On-hours vs. off-hours were defined using the weekend variable. Age groups were divided into 18-39, 40-59, 60-79 and ≥80 years. An age groupwise multivariable logistic regression models were used to compare odds of EVT and IV-rtPA use between on-hours vs. off-hours. Result: Total 4.5 million AIS population comprised 2.1% of 18-39 years, 20.0% of 40-59 years, 44.1% of 60-79 years and 34.0% of ≥80 years. Off-hours admissions comprised 25.7% of total AIS. Univariate analysis of off-hours vs. on-hours effects showed EVT utilization was 2.2% vs. 2.3% (P=0.50) and IV-tPA use was 7.9% vs. 7.3% (P=0.18) in 18-39 years. In 40-59 years age group, EVT 1.19% vs. 1.17% (P=0.74) and IV-tPA 6.2% vs. 5.7% (P &lt;0.0001). In 60-79 years, EVT 0.95% vs. 0.96% (P=0.87) and IV-tPA 5.5% vs. 5.0% (P &lt;0.0001) and in ≥80 years, EVT was 0.5% vs. 0.6% (P=0.12) and IV-tPA was 4.7% vs. 4.4% (P &lt;0.0001). After a multivariable adjustment of patients and hospital characteristics, odds of EVT utilization was 0.85 (P=0.18) in 18-39 years, 0.92 (P=0.13) in 40-59 years, 0.91 (P=0.014) in 60-79 years and 0.84 (P=0.003) in ≥80 years. While in IV-tPA group, odds of IV-tPA use was 1.09 (P=0.16) in 18-39 years, 1.08 (P=0.001) in 40-59 years, 1.09 (P &lt;0.0001) in 60-79 years and 1.07 (P=0.002) in ≥80 years. Conclusion: Our study concludes that there is a lower rate of EVT performed during off-hours in the age groups of 60-79 and ≥ 80 years old. However, There was no difference reported in the use of EVT in the younger population. It’s also interesting to note that there is a higher use of IV-rtPA during the off-hours in all age groups except age group 18-39 years.

Epidemiology and Trends of Hereditary Hemorrhagic Telangiectasia in the United States.

BackgroundTo our knowledge, no national studies have investigated the epidemiology of hereditary hemorrhagic telangiectasia (HHT) in the United States since the incorporation of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10 CM).ObjectiveOur objective is to analyze the epidemiology of HHT from 2013 to 2017 and to determine the relationships between epistaxis and other associated complications of this rare disease.MethodsWe analyzed the epidemiology of HHT between 2013 and 2017 by accessing data of 87 709 738 patients from the Clinformatics Data Mart using ICD-9 CM and ICD-10 CM codes. Variables analyzed included age, gender, region, clinical setting of diagnosis, hospitalizations, and complications. Bivariate analyses using generalized linear models were conducted to determine the likelihood of HHT patients with epistaxis enduring associated life-threatening complications such as cerebral hemorrhage, thrombosis, and pulmonary hemorrhage compared to HHT patients without epistaxis during the study period.ResultsThe prevalence of HHT increased from 6.1 to 12.1 per 100 000 persons, with patients of ages 18 to 29 years and those older than 60 years seeing the greatest percent increase. The prevalence of HHT in the Southern United States saw a 147% increase. Compared to HHT patients without epistaxis, HHT patients with epistaxis were 3.4 times more likely to experience pulmonary hemorrhage, 3.3 times more likely to have pulmonary emboli, 2.8 times more likely to experience cerebral hemorrhage, and 2.0 times more likely to have thrombosis during the study period.ConclusionOur national study has provided the first incidence and prevalence rates of HHT in the United States since the incorporation of the ICD-10 CM. HHT patients with epistaxis require prompt multidisciplinary treatment of their condition due to their increased risk of life-threatening complications.

Anaemia under-reporting in a hospital setting in Italy

Abstract Background Anaemia is a common occurrence in the general population, affecting nearly one in three people worldwide, with peaks in the elderly and those with chronic diseases or micronutrient deficiency. If recognised, anaemia can often be treated through micronutrient administration, thus an early recognition of the disorder has a significant return in terms of Public Health and of investment. Methods Hospitalisation records from a large sample of ordinary admissions over a year (2016) were retrospectively analysed, in order to assess the impact of hospital stay on anaemia prevalence, defined according to WHO criteria. Prevalence was estimated by both haemoglobin levels and anaemia-related description codes (ICD9CM) at discharge. Furthermore, the main diagnoses associated with loss of haemoglobin were investigated, using binary logistic regression. Results Over the 15,624 ordinary admissions, we found the prevalence rate of anaemia was 47.2% at hospital admission, increasing to 63.9% at discharge. During hospital stay, a mean reduction of 0.323 g/dl (SD ± 1.39) haemoglobin was recorded, in particular those with neurological, circulatory, and haematological diseases (p &amp;lt; 0.001). By comparing the two diagnostic criteria, a great under-reporting occurred in 85.3% patients with haemoglobin levels predictive for anaemia at hospital discharge. Conclusions Our results highlight the importance of correctly identifying anaemia in the hospital setting as a main Public Health concern. Since haemoglobin loss is recorded during hospital stay, we propose measuring haemoglobin levels not only at admission, but also at discharge, and to enhance proper ICD9CM code inclusion in discharge records. The achievement of both these good practices would have a double effect: to properly inform all the stakeholders and to allow more than half hospital patients, those with haemoglobin levels predictive for anaemia but without specific ICD9CM code at discharge, to be cured in the proper setting. Key messages Anaemia often remained misidentified during hospitalisation, thus inducing a decrease in mean inpatients haemoglobin levels and a consequent increase of anaemia prevalence at discharge. Despite this worsening during hospital stay, a significant underreporting was recorded: 85.3% patients with Hb levels predictive for anaemia at hospital discharge had no specific ICD9CM code.

Mesothelioma: a rare cancer in the Valencian Region’s Cancer Registry (Spain)

Abstract Background Malignant mesothelioma is a rare type of cancer. The estimated incidence in Spain is 535 cases per year, being more frequent in men and reaching the highest rate of incidence between the ages of 60-70. Objective: to determine the characteristics of those affected by the mesothelioma in the Valencian Region during the period 2005-2016 and identify the temporary evolution. Methods A cross-sectional study was performed. Cases were identified through the Valencian Region’s Cancer Registry (VCR), those registered between 2005-2015 were identified by the ICD9-CM (code 163*) and 2016’s by the ICD10 (code C45). Cases were validated through the review of clinical documentation. The incidence and mortality were calculated and a descriptive analysis was developed including clinical, demographic and social characteristics. Results 379 cases were identified and confirmed. 58.4% of the cases were men and the average age of diagnosis was 67 years. 85.1% were Spanish. 87.3% of cases had died and the average age of death was 70 years. An increasing incidence has been observed, being 11.4/1000000 inhabitants (CI95%:8.4-14.3) in 2016. The malignant mesothelioma morphology distribution was: 45.1% epithelial, 43.8% non-specified, 6.6% fibrous and 4.5% in two-phase. In 90.8% of the cases the assessment used to confirm the diagnosis was the primary tumour’s histology, in 3.7% was a cytology or hematologic analysis, in 2.6% was metastatic tissue histology, in 1.3% were clinical signs, in 0.5% was other clinical test like MRI/CT scan, in 0.3% was a postmortem histology and in 0.8% assessment was unknown. Conclusions The data about mesothelioma included in the VCR could be considered solid due to the results obtained through the validation. The mesothelioma’s malignancy it is evident, despite its low incidence, its mortality rate is high. The increasing trend observed is in agreement with those experts who estimate that the highest rate of incidence will be between the years 2020-2040. Key messages The data about mesothelioma recorded in the Valencian Region’s Cancer Registry could be considered solid due to the results obtained through the validation of information procedure. The increasing trend of malignant mesothelioma observed is in agreement with those experts who estimate that the highest rate of incidence will be between the years 2020-2040.