Large Bed Size Research Articles

In-hospital mortality in acute promyelocytic leukemia patients: A study of national inpatient sample.

e18521 Background: Acute Promyelocytic Leukemia (APL), a subtype of acute myeloid leukemia, has excellent outcomes, but continues to show high rates of early mortality. An epidemiologic study utilizing SEER between 1992 & 2007 showed an early death rate of 17.3%. There is limited data on the incidence of inpatient mortality in APL patients in the United States and the factors that contribute to early death. Methods: National Inpatient Sample was utilized to identify adult patients (≥18 years) diagnosed with APL using International Classification of Diseases, 10th edition (ICD-10-CM) code C92.40. Since the United States transitioned from using ICD-9-CM to ICD-10-CM on October 2015, we included APL patients diagnosed between 2015 & 2016. Clinical, sociodemographic and hospital characteristic data were examined; hospital volume was divided into quartiles. The association between overall inpatient survival & receipt of chemotherapy was examined in a propensity score matched cohort of patients not discharged to another acute care facility. Statistical analyses were conducted utilizing SAS version 9.4. Results: In total, 433 APL patients were identified (median age 52 years, 52% males, 65% whites). The inpatient mortality rate was 9.93%. 59.5% (n = 258) of patients did not receive chemotherapy. On univariate-analysis, patients with younger age, black-race, transfer in from other hospital, elective admissions, private insurance, large bed size hospital & large hospital volume were more likely to receive chemo. In the matched-cohort, receipt of chemo was associated with decreased mortality (Hazard Ratio 0.27, 95% CI: 0.12-0.60). We ran additional mortality analysis landmarked at 3 days and 7 days: 75% of chemo patients receiving treatment within 3 days had survival advantage with chemo (HR: 0.35 [0.15-0.82]). 90% of chemo patients receiving treatment within 7 days didn’t show any difference in survival (HR: 0.49 [0.18-1.32]) but the sample size was small. Conclusions: Our study showed an early survival benefit when patient with APL received chemotherapy within 3 days of admission. Early recognition & prompt treatment initiation will help reduce the rate of early mortality in patients with APL.

Utilization of Palliative Care for Patients Undergoing Hematopoietic Stem Cell Transplantation During Hospitalization: A Population-Based National Study.

Patients undergoing hematopoietic stem cell transplantation (HSCT) have substantial physical and psychological symptoms. This study aimed to investigate the utilization of palliative care (PC) in patients undergoing HSCT during hospitalization. The 2008-2014 National Inpatient Sample was queried for eligible participants. Demographics, hospital characteristics, comorbidities, posttransplantation complications, and inpatient procedures were compared between patients with and without PC. Multivariate logistic regression was performed to identify predictors associated with PC use. Among 21 458 patients undergoing HSCT during hospitalization, 278 (1.30%) received PC. The rate of PC use has significantly increased from 0.64% in 2008 to 1.95% in 2014. Patients receiving PC had more co-comorbidities, posttransplantation complications, inpatient procedures, and were more likely to carry a diagnosis of leukemia. In allogeneic HSCT, large bed size (odds ratio [OR] =2.80; 95% confidence interval [CI]: 1.17-6.70), stem cell source from cord blood (OR = 1.93; 95% CI: 1.15-3.24), and graft-versus-host disease (OR = 2.04; 95% CI: 1.36-3.06) were predictors of PC use. In a subset analysis of 783 patients who died during hospitalization, 166 (21.20%) received PC. Among the decedents, Hispanic race had lower odds of PC use (OR = 0.20; 95% CI: 0.05-0.82) in allogeneic HSCT and women had higher odds of PC (OR = 2.70; 95% CI: 1.35-5.41) in autologous HSCT. The rate of PC use has significantly increased among patients undergoing HSCT during hospitalization from 2008 to 2014 but still remains very low. Further investigation is warranted to verify and better understand the barriers toward PC use for HSCT patients.

Performance and outcome of pelvic exenteration for gynecologic malignancies: A population-based study

ObjectiveTo examine changes in performance and outcomes of pelvic exenteration for gynecologic malignancies. MethodsThis is a population-based retrospective study examining the Nationwide Inpatient Sample between 2001 and 2015. Women with cervical, uterine, vaginal, and vulvar malignancies who underwent pelvic exenteration were examined. Comorbidity, perioperative complications, total charges, length of stay, and mortality were assessed. ResultsThere were 2647 cases included. Cervical cancer was the most common malignancy (45.1%), followed by vaginal cancer (27.6%). 26.9% of women had a Charlson Comorbidity Index ≥3, which significantly increased from 23.3% in 2001–2005 to 33.3% in 2011–2015 (42.9% relative increase, P < 0.001). Obese women undergoing exenteration increased significantly from 4.5% in 2001–2005 to 19.4% in 2011–2015 (3.3-fold relative increase, P < 0.001). The perioperative complication rate was 68.1%, including 38.7% with multiple complications. The mortality rate was 1.9%. The number of women with multiple perioperative complications increased from 29.4% in 2001–2005 to 52.8% in 2011–2015 (78.6% relative increase, P < 0.001). More recent year of surgery, obesity, higher comorbidity, higher household income, surgery at large bedsize hospital, urinary diversion, vaginal reconstruction, and vulvar cancer were associated with an increased risk of multiple complications on multivariable analysis (all, P < 0.05). Median length of stay was 14 (IQR 9–21) days, and the number of women hospitalized ≥28 days significantly increased from 12.6% in 2001–2005 to 19.1% in 2011–2015 (51.6% relative increase, P < 0.001). The median corrected total charges increased from $121,854 to $185,100 between 2001 and 2015 (net difference +$63,246, 51.9% relative increase, P < 0.001). ConclusionWomen undergoing pelvic exenteration for gynecologic malignancies became more obese and comorbid during the study period. Pelvic exenteration for women with gynecologic malignancies is associated with high morbidity and mortality as well as substantial treatment-related costs.

Abstract WP446: Predictors of 30-Day Readmissions and in Hospital Mortality Following Intracerebral Hemorrhage (ich)-A 5-Year National Estimate

Background: Intracerebral hemorrhage (ICH) is one of the more devastating types of stroke with worse short-term outcomes. There is a paucity of data regarding preventable causes of readmission and predictors of short-term outcomes post-ICH. Method: Nationwide Readmissions Database (NRD) from 2010-14 was utilized to identify ICH using appropriate ICD-9CM codes in the primary diagnostic field. Admissions within 30 days of discharge were considered as early readmission and predictors to assess an association between baseline characteristics and 30-day readmission and mortality were analyzed using multivariable logistic regression model. Result: We identified 276,401 patients with ICH in our study, of which 37,689 (10%) were readmitted within 30 days (Mean age 68.3 years; 52.8% male). Hypertension was the major comorbidity in the readmitted population (77.7%) followed by diabetes (33.5%), anemia (21.9%), and atrial fibrillation (20.7%). Comorbid conditions like diabetes, heart failure, atrial fibrillation (AF), anemia, coagulopathy, chronic renal failure (CRF), valvular heart disease (VHD), liver disease, in-hospital septicemia, urinary tract infection, Pneumonia, deep venous thrombosis and discharge to another facility were significant predictors of 30-day readmission. Advancing age, heart failure, AF, CRF, liver disease, coagulopathy, hospitalization on weekends, in-hospital complications such as acute renal failure, sepsis, pneumonia was predictive of increased 30-day mortality. Non-emergent index admissions in large bed size, teaching hospital and private insurance were associated with decreased mortality. Conclusion: In conclusion, ICH was associated with a 10% readmission rate during our study period. Identification of high-risk population based on certain preexisting comorbidities and in-hospital complications, better follow up and transition of care can have improved outcomes in these patients and reduce healthcare burden.

Assessing the Quality of Microvascular Breast Reconstruction Performed in the Urban Safety-Net Setting: A Doubly Robust Regression Analysis.

Safety-net hospitals serve vulnerable populations; however, care delivery may be of lower quality. Microvascular immediate breast reconstruction, relative to other breast reconstruction subtypes, is sensitive to the performance of safety-net hospitals and an important quality marker. The authors' aim was to assess the quality of care associated with safety-net hospital setting. The 2012 to 2014 National Inpatient Sample was used to identify patients who underwent microvascular immediate breast reconstruction after mastectomy. Primary outcomes of interest were rates of medical complications, surgical inpatient complications, and prolonged length of stay. A doubly-robust approach (i.e., propensity score and multivariate regression) was used to analyze the impact of patient and hospital-level characteristics on outcomes. A total of 858 patients constituted our analytic cohort following propensity matching. There were no significant differences in the odds of surgical and medical inpatient complications among safety-net hospital patients relative to their matched counterparts. Black (OR, 2.95; p < 0.001) and uninsured patients (OR, 2.623; p = 0.032) had higher odds of surgical inpatient complications. Safety-net hospitals (OR, 1.745; p = 0.005), large bedsize hospitals (OR, 2.170; p = 0.023), and Medicaid patients (OR, 1.973; p = 0.008) had higher odds of prolonged length of stay. Safety-net hospitals had comparable odds of adverse clinical outcomes but higher odds of prolonged length of stay, relative to non-safety-net hospitals. Institution-level deficiencies in staffing and clinical processes of care might underpin the latter. Ongoing financial support of these institutions will ensure delivery of needed breast cancer care to economically disadvantaged patients. Therapeutic, III.

Variation of hospital-based adoption of care coordination services by community-level social determinants of health.

Hospital investments in care coordination services and innovative delivery models represent an important source for improving care efficiency and population health. The aim of this study was to explore variation of hospital-initiated care coordination services and participation in Accountable Care Organizations (ACOs) by community characteristics within an organizational theory framework. Our main data sets included the 2015 American Hospital Association Annual Survey, Survey of Care Systems and Payment, American Community Survey, and Area Health Resource File. Two main outcomes were (a) hospital-reported initiation of care coordination practices (such as chronic disease management, post-hospital discharge continuity of care, and predictive analytics) and (b) participation in ACO models. State fixed-effects models were used to test the association between the adoption of care coordination practices and hospital characteristics, community-level sociodemographic characteristics, and health policies. Hospitals with large bed size, located in urban areas, and/or with high volume of operations were more likely to adopt care coordination practices and participate in the ACO models. Hospitals serving communities with high uninsurance rates and/or poverty rates were significantly less likely to provide care coordination practices. More stringent Community Benefit Laws (CBLs) were positively associated with the implementation of care coordination practices suggesting strong normative impacts of CBLs. Greater hospital-initiated care coordination practices and innovative ACO models were available in well-resourced areas. Policymakers may consider increasing resources for care coordination practices in rural, underserved, and high-poverty-high-uninsured areas to ensure that vulnerable populations can benefit from these services.

1763. Estimating Median Survival Time to Central Line-Associated Bloodstream Infection (CLABSI) Among Patients in Intensive Care Units Reported to National Healthcare Safety Network (NHSN)

BackgroundDuration free of central line-associated bloodstream infection (CLABSI) in a hospital may vary by type of patient population. We estimated patients’ median time to CLABSI by intensive care unit (ICU) type among acute care hospitals.MethodsThe study population was ICU patients whose CLABSI data were reported to National Healthcare Safety Network (NHSN) in 2016 under the reporting requirement of the Centers for Medicare and Medicaid. The unit of analysis was ICU location, not an individual patient. We conducted counting process survival analysis method to compute time (day) to a CLABSI beginning from day 1 of first reporting month in 2016 in a given ICU location. Once a CLABSI occurred in a location, the start time of follow-up was reset to day 1 after the date of event. The Cox regression method was used to explore the hospital and location-level characteristics that are potentially associated with the daily hazard of CLABSI for an ICU. We also assessed the proportionality hazard assumption of these factors. Adjusting for the vector of means of covariates, we then estimated median time to CLABSI by ICU location type, which is defined as follow-up time (days) by which 50% of events have happened in a given ICU type.ResultsIn 2016, 6,935 ICUs at 3,384 hospitals reported CLABSI data to NHSN, with a total of 10,985 CLABSIs and 2,449,361 follow-up time in days. Factors associated with an increased daily hazard of CLABSI were the following: admission to a hospital with a large bed size, major teaching status, and admission to a patient care location with a higher device utilization ratio (Table 1). Adjusted survival curves showed that median time to event (median CLABSI-free time) among ICUs ranged from 66 days (level III neonatal ICU), 90 days (burn units) to 275 days (oncology units), and 284 days (cardiothoracic units) (Table 2, Figure 1).ConclusionThe study demonstrated that ICUs with level III care for neonatal patients and ICUs with burn patients were least likely to achieve the target of “zero” infection in a defined period and may warrant further targeted interventions. Similar research to investigate infection control performance through estimating median infection-free time is needed beyond ICUs and across multiple HAI types and facility settings. Disclosures All authors: No reported disclosures.

Abstract 02: Association Between Hospital Volume of Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest and Survival to Hospital Discharge

Background: Prior studies have shown that hospital case volume is not associated with survival in patients with out-of-hospital cardiac arrest (OHCA). However, how case volume impact on survival for in-hospital cardiac arrest (IHCA) is unknown Methods: We queried the National Inpatient Sample (NIS) in the U.S. 2005-2011 to identify cases in which in-hospital CPR was performed for IHCA. Years &gt; 2011 were excluded due to redesign of NIS that precludes case volume calculation. Restricted cubic spine was used to evaluate the association between hospital annual CPR volume and survival to hospital discharge. Further analysis was conducted with case volume in quartiles. Results: Across more than 1000 hospitals in NIS, we identified 137,466 cases (mean age 67, 45% female) of IHCA for which CPR was performed over the study period. Median [Q1, Q3] case volume was 68 [34, 100]. Compared to those in the 1 st quartile (q1) of case volume, hospitals in the 4 th quartile (q4) tends to have younger patients (mean=66 vs 68 yrs), higher comorbidities (median Elixhauser score=4 vs 3), large bed size (89 vs 37%), and in low income areas (37 vs 32%). After adjustment for patient and hospital factors, higher hospital case volume was inversely associated with lower rates of survival (Fig1). Risk-adjusted rates of survival from q1 through q4 were: 28.1%, 25.5%, 25.4% and 23.7%. We arrived at similar results when analysis was stratified by age, gender and hospital bed size (not shown) except that the difference across quartiles was more pronounced among small bed size hospitals (survival rate=27.4% in q1 vs 8.1% in q4). However, among those who survived to hospital discharge, nonroutine home discharge was higher among patients in q1 (73.9%) vs q4 (69.6%) Conclusion: Unlike OHCA, hospital case volume is inversely associated with survival to hospital discharge in patients undergoing CPR for IHCA. Hence, quality measures to reduce the incidence of CPR/IHCA have the potential to reduce in-hospital mortality

Abstract A29: Multilevel factors associated with increased in-hospital length of stay among patients following head and neck cancer treatment

Abstract Background: Head and neck cancer (HNC) treatment often involves extensive surgical procedures, which require patients to be hospitalized. Increased hospital stay following HNC treatment contributes substantial costs to both the patient and the hospital, and is considered an indicator of quality of care. Cost containment is at the forefront of responsible health care delivery, and one way to decrease costs is to decrease hospital length of stay (LOS). To reduce hospital LOS and decrease cost of treating HNC patients, it is important to first characterize factors associated with increased hospital LOS. However, data are lacking on factors contributing to increased LOS in patients with HNC. This study aims to examine predictors of length of stay among patients following HNC cancer treatment in a national sample. Methods: Data on 75,984 hospital records from the Nationwide Inpatient Sample 2008 – 2013 with a diagnosis of HNC using the International Classification of Diseases, ninth edition, were examined. The outcome variable, LOS, was calculated by subtracting the admission date from the discharge date, with same-day stays coded as 0. Patient level characteristics included age, sex, race, insurance type, residential income, comorbidity score, metastatic cancer status, and anatomic site. Hospital-level characteristics included hospital teaching status, hospital bed size, and hospital regional location. Weighted, multilevel generalized model was used to assess correlates of LOS. Results: Mean LOS among cases was 6.7 ± 8.0 days. The adjusted multilevel analysis indicated that patients with advanced comorbidities (b = 2.17 per 1 unit increase in Elixhauser comorbidity score, 95% CI = 1.66 – 2.69) were more likely to have a longer LOS. Compared with women, men were more likely to have a longer LOS (b = 0.20, 95% CI = 0.06, 0.33), as well as African Americans (b = 0.31, 95% CI = 0.11, 0.49) compared with Caucasians. In addition, patients with Medicaid (b = 1.38, 95% CI = 1.19, 1.58) vs. private insurance payers and those with metastatic cancer (b = 1.21, 95% CI = 1.07, 1.35) had longer LOS. Patients were more likely to have longer LOS if the sites of their cancer were floor of the mouth (b = 3.51, 95% CI = 3.12, 3.89), hypopharynx (b = 3.05, 95% CI = 2.68, 3.41), gum (b = 2.79, 95% CI = 2.34, 3.23), or larynx (b = 2.43, 95% CI = 2.15, 2.70) compared with salivary gland. Hospital-level factors also were associated with LOS among HNC patients in the adjusted multilevel model. Patients admitted to hospitals located in the South (b = -0.82, 95% CI = -1.11, -0.52), Midwest (b = -1.63, 95% CI = -1.98, -1.28), and West (b = -0.73, 95% CI = -1.08, -0.39) had shorter LOS compared with those admitted to hospitals located in the Northeast. Finally, patients admitted to a nonteaching hospital (b = -0.87, 95% CI = -1.08, -0.66), and small bed size (b = -0.95, 95% CI = -1.30, -0.60) or medium bed size (b = -0.58, 95% CI = -0.82, -0.34) hospital vs. large bed size had shorter LOS. Conclusion: Other than the index head and neck cancer, comorbidities seem to be the most important factor associated with increased patient LOS. Additionally, male patients, African Americans, those who had Medicaid insurance, had metastatic cancer, and were admitted to a teaching hospital were more likely to stay at the hospital longer. Understanding these factors associated with increased LOS will help efforts to decrease health care cost and improve quality of care. Citation Format: Eric Adjei Boakye, Betelihem B. Tobo, Jiajing Chen, Paula Buchanan, Shubhra Malik, Nosayaba Osazuwa-Peters. Multilevel factors associated with increased in-hospital length of stay among patients following head and neck cancer treatment [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A29.

Abstract TMP39: Patterns of Discharge Antidepressant Therapy Use After Acute Ischemic Stroke: Insights From the Prosper Study

Background: Antidepressant (AD) therapy has been shown to improve post-stroke depressive symptoms, yet few data are available on characteristics associated with treatment at the time of discharge after ischemic stroke. Methods: PROSPER is a PCORI-funded study designed by researchers and stroke survivors to evaluate the effectiveness of therapies post-stroke. We used information from ischemic stroke patients discharged from April 2014 - December 2014 in the American Heart Association’s Get With The Guidelines (GWTG)-Stroke registry who were linked to Centers for Medicare and Medicaid Services (CMS) data to evaluate antidepressant medication use following hospitalization for ischemic stroke. Results: Of 29,177 eligible patients from 1,023 hospitals, n=7,593 (26.0%) were prescribed AD at hospital discharge. The majority of discharge AD prescriptions were for an SSRI (70.6%) and in patients with history of depression and on AD prior to admission. Patients discharged on an AD were more likely to be female, of white race, and to have a prior history of cardiovascular diseases (Table). Discharge AD prescription was more common at teaching hospitals, hospitals with larger bed size and higher annual volume of ischemic stroke admissions. Amongst the patients who were not on AD prior to admission (22,437), only 8.1% were discharged on AD. Patients discharged on AD amongst AD naïve population were more likely to be female, of white race, had prior history of depression, had higher initial NIHSS and more likely to be discharged to a facility. Conclusions: Among CMS linked patients, antidepressant prescription after ischemic stroke is low and varies by key patient and hospital level characteristics. Future research examining the association between discharge AD use and patient reported outcomes after stroke is needed.

Abstract: Syndactyly: National Analysis of Trends in Epidemiology and Surgical Management from 1997–2012

INTRODUCTION: Syndactyly is a common congenital hand deformity with an estimated incidence of 1:2000 live births.1 Previous studies have discussed disparities in the provision of hand and upper limb services in the United States.2 Our study aims are to (1) analyze the epidemiology of syndactyly and trends in surgical management over time; (2) identify socioeconomic disparities affecting treatment. METHODS: A retrospective analysis of the Healthcare Cost and Utilization Project Kids Inpatient Database was performed for all available years (1997, 2000, 2003, 2006, 2009, 2012). Children under the age of three with a diagnosis of syndactyly were retrieved using International Classification of Diseases, Ninth Revision diagnosis codes (ICD-9 755.11, 755.12, 755.55); procedural data for syndactyly correction were also retrieved. Trends over time were analyzed using the Cochran-Armitage test. Patient and hospital characteristics underwent multivariable logistic regression modeling to evaluate predictors of surgical treatment. RESULTS: Overall, 6,401 cases of syndactyly were retrieved over the study period, with an incidence of 16.32/million in 2012. The majority were Caucasian (59.1%) and male (61.5%), admitted to Southern (35.6%), large bed size (59.2%), urban, teaching hospitals (63.3%), with either predominantly Private (49.6%) or Government-based insurance (44.0%). Of these, 12.8% (n=821) underwent procedures for syndactyly correction. Over time there was a significant decrease in surgical correction of syndactyly (20.5% in 1997 to 6.0% in 2012, p<0.001). Of those having surgery, there has been a significant increase in flap-based reconstruction of the hand over time (12.2% in 1997 to 30.6% in 2012, p<0.001). Predictors of not having surgical treatment for syndactyly were Medicaid coverage (OR 1.253, CI 1.066–1.471); lowest three incomes quartiles (OR 1.29, CI 1.051–1.584; OR 1.404, CI 1.152–1.712; OR 1.281, CI 1.062–1.545); admission to a medium (OR 1.248, CI 1.021–1.526), large (OR 1.597, CI 1.321–1.931), urban non-teaching (OR 1.899, CI 1.360–2.653), urban teaching (OR 1.152, CI 1.772–2.615) or Midwestern (OR 1.324, CI 1.054–1.663) hospital. CONCLUSION: The surgical correction of syndactyly within the inpatient setting is decreasing over time. Socioeconomic disparities are evident: Medicaid insurance status and lower household income had significantly lower rates of surgical correction. Minimizing socioeconomic barriers to care may be important steps in enhancing the quality of care that is delivered to vulnerable pediatric populations. Reference Citations: 1. Jordan D, Hindocha S, Dhital M, Saleh M, Khan W. The epidemiology, genetics and future management of syndactyly. Open Orthop J. Bentham Science Publishers; 2012;6:14–27. 2. Squitieri L, Steggerda J, Yang LJ-S, Kim HM, Chung KC. A National Study to Evaluate Trends in the Utilization of Nerve Reconstruction for Treatment of Neonatal Brachial Plexus Palsy [Outcomes Article]. Plast Reconstr Surg [Internet]. 2011;127:277–83.

Information technology to support patient engagement: where do we stand and where can we go?

Given the strong push to empower patients and make them partners in their health care, we evaluated the current capability of hospitals to offer health information technology that facilitates patient engagement (PE). Using an ontology mapping approach, items from the American Hospital Association Information Technology Supplement were mapped to defined levels and categories within the PE Framework. Points were assigned for each health information technology function based upon the level of engagement it encompassed to create a PE-information technology (PE-IT) score. Scores were divided into tertiles, and hospital characteristics were compared across tertiles. An ordered logit model was used to estimate the effect of characteristics on the adjusted odds of being in the highest tertile of PE-IT scores. Thirty-six functions were mapped to specific levels and categories of the PE Framework, and adoption of each item ranged from 23.5 to 96.7%. Hospital characteristics associated with being in the highest tertile of PE-IT scores included medium and large bed size (relative to small), nonprofit (relative to government nonfederal), teaching hospital, system member, Midwest and South regions, and urban location. Hospital adoption of PE-oriented technology remains varied, suggesting that hospitals are considering how technology can create partnerships with patients. However, PE functionalities that facilitate higher levels of engagement are lacking, suggesting room for improvement. While hospitals have reached modest levels of adoption of PE technologies, consistent monitoring of this capacity can identify opportunities to use technology to facilitate engagement.

Variation in Hospital Use and Outcomes Associated With Pulmonary Artery Catheterization in Heart Failure in the United States.

There has been an increase in the use of pulmonary artery (PA) catheters in heart failure (HF) in the United States in recent years. However, patterns of hospital use and trends in patient outcomes are not known. In the National Inpatient Sample 2001 to 2012, using International Classification of Diseases-Ninth Revision codes, we identified 11 888 525 adult (≥18 years) HF hospitalizations nationally, of which an estimated 75 209 (SE 0.6%) received a PA catheter. In 2001, the number of hospitals with ≥1 PA catheterization was 1753, decreasing to 1183 in 2011. The mean PA catheter use per hospital trended from 4.9 per year in 2001 (limits 1-133) to 3.8 per year in 2007 (limits 1-46), but increased to 5.5 per year in 2011 (limits 1-70). During 2001 to 2006, PA catheterization declined across hospitals; however, in 2007 to 2012, there was a disproportionate increase at hospitals with large bedsize, teaching programs, and advanced HF capabilities. The overall in-hospital mortality with PA catheter use was higher than without PA catheter use (13.1% versus 3.4%; P<0.0001); however, in propensity-matched analysis, differences in mortality between these groups have attenuated over time-risk-adjusted odds ratio for mortality for PA catheterization, 1.66 (95% confidence interval, 1.60-1.74) in 2001 to 2003 down to 1.04 (95% confidence interval, 0.97-1.12) in 2010 to 2012. There is substantial hospital-level variability in PA catheterization in HF along with increasing volume at fewer hospitals over-represented by large, academic hospitals with advanced HF capabilities. This is accompanied by a decline in excess mortality associated with PA catheterization.

An Analysis of Patients Treated for Cerebrospinal Fluid Rhinorrhea in the United States from 2002 to 2010.

Background The Nationwide Inpatient Sample (NIS) database was used to analyze the demographic features and concomitant diagnoses in patients admitted with cerebrospinal fluid (CSF) rhinorrhea. Methods We analyzed the NIS database for all hospital admissions of CSF rhinorrhea between 2002 and 2010. Patient demographics, length of stay, hospital charges, concomitant diagnoses, hospital level characteristics, and complications were analyzed for patients undergoing surgical repair (group I) and for those treated without surgical repair (group II). Results Patients in group I were significantly older, the majority were female (67.5%), and were more likely to be obese (12.9%), have diabetes mellitus (15.7%), and hypertension (41.6%). Lengths of stay were similar between the two groups, but group I patients incurred higher hospital charges (p < 0.001). Group I patients were more likely classified as an elective admission (59.8 vs. 38.6%), and were more frequently admitted to a teaching hospital (83.6%) with a large bed size (79.0%). Acute medical complications and concomitant diagnosis of meningitis were similar in both groups. Conclusion Rates of meningitis did not differ between the two groups. Patients who underwent surgical repair were more likely to be an elective admission and admitted to a teaching hospital. Hospital charges were higher in patients undergoing repair.

Analysis of outcomes of percutaneous coronary intervention in metastatic cancer patients with acute coronary syndrome over a 10-year period.

Early medical palliative care has been shown to improve overall survival of patients with metastatic cancer, but the role of cardiac surgical interventions in such patients is not clear. The limited life expectancy of these patients often poses a dilemma to clinicians and involves a detailed analysis of the risks and benefits of such interventions. This study examines the outcomes of percutaneous coronary intervention (PCI) in patients with metastatic cancer. The National Inpatient Database of USA was used to identify patients aged ≥ 1 8 years who had a diagnosis of metastatic cancer and acute coronary syndrome (ACS) between 2000 and 2009 using ICD-9-CM codes. These were categorized into ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). The utilization of PCI was also identified using ICD-9-CM codes. The outcomes studied were in-hospital mortality, length of hospital stay and discharge disposition. The association between various outcomes and use of cardiac catheterization was assessed using multivariate regression models. There were 49,515 patients with metastatic disease who were discharged with a diagnosis of ACS. Of these, 15,964 had STEMI and 33,551 had NSTEMI. 3981 patients (24.9%) with STEMI and 3209 patients (9.6%) with NSTEMI received percutaneous coronary intervention. Caucasian male patients under age 65 years were more likely to receive PCI in the setting of an ACS. The hospital characteristics associated with higher use of PCI included academic affiliation, large bedsize, private for-profit hospitals and Midwestern and Western regions of USA. The adjusted odds of receiving PCI in this group of patient have gradually increased by 1.14 every year in last decade (95% CI 1.11-1.16). The beneficial effect of PCI on in-hospital mortality has declined in NSTEMI such that by 2009, there was no significant difference between patients who received PCI and those who did not receive PCI. This has remained unchanged for STEMI patients.C ONCLUSIONS: In metastatic cancer patients with ACS, the rate of PCI has increased over the last decade. In the current era, metastatic cancer patients with NSTEMI may perform equally well without PCI in terms of in-hospital mortality. The decision to provide such care may be considered on an individual basis based on the extent of their medical comorbidity and tumor burden.

Assessing Unmet and Latent Demand for Pharmacists at the State Level.

Past reports suggest that a near balance has been reached in the supply and demand for pharmacists in the US. Although data on the level of supply of pharmacists is available, there is no continuous and systematic tracking of the level of demand (unmet and latent) for pharmacists at state level. Unmet demand, an established construct in pharmacy workforce, is important to measure the number of vacancies and assess pharmacist shortage consistently over time. Latent demand or potential demand is a novel construct and has never been measured in pharmacy workforce. With the increase in supply, it is important to measure the potential demand that could be budgeted in pharmacies in the near future. The objective of this study was to measure the unmet and latent demand for pharmacists and explore the association between latent demand and workload characteristics in community and hospital pharmacies in Wisconsin in 2011-12. The study used a cross-sectional, descriptive survey design. A sample of community pharmacies (n=1,064) and hospital pharmacies (n=126) licensed in Wisconsin in 2011-12 was identified. Key informants (managers/owners) of sampled pharmacies were sent a one-page cover letter explaining the purpose of the study and requesting participation and a three page survey form. The main outcome measures of the study were total number of FTE pharmacist positions vacant, presence of adequate staff size, additional number of FTE pharmacist positions needed to attain adequate staff size, prescription volume, daily census, hospital size and number of hours prescription department is open. Descriptive statistics were calculated for all the pharmacies collectively, then separately for community and hospital pharmacies. Pharmacy setting, vacancies and workload characteristics of pharmacies with and without latent demand were compared using chi-squared test of independence and/or t-test. Sample weights were calculated and used in all the analyses to weigh the estimates to all pharmacies in Wisconsin. Overall response rate to the survey was 50.1%. Of the total number of FTE pharmacist positions budgeted in Wisconsin, 54.3 FTE positions (1.5%) were reported vacant in 2011-12. Approximately 28.2% of the community and hospital pharmacies reported the presence of latent demand. Latent demand was significantly associated with higher workload in community pharmacies and larger bed size in hospital pharmacies. There appeared to be a balance between the supply and demand for pharmacists in Wisconsin in 2011-12. There is a potential for additional FTE positions (latent demand) to be budgeted in pharmacies to attain adequate pharmacist staff size. It is important to consistently track the level of unmet and latent demand for pharmacists in Wisconsin and combine this information with other workforce characteristics to guide the decision making of pharmacy workforce planners and pharmacy managers.

Predictors of in-Hospital Mortality in Tumor Lysis Syndrome

BackgroundMorbidity and mortality in tumor lysis syndrome (TLS) remains high despite increasing efforts for prevention, early detection and treatment in recent years. The current risk stratification system and treatment guidelines are largely consensus based without strong evidence. There is paucity of data on the in-hospital mortality and predictors of poor clinical outcome in this population.MethodsWe used the 2009-2011 Nationwide Inpatient Sample database to identify hospitalizations in patients ≥18 years with a diagnosis of TLS (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 277.88). Nationwide Inpatient Sample is the largest all-payer publicly available inpatient care database in the US. It contains data from five to eight million hospital stays from about 1,000 hospitals across the country and approximates a 20% sample of all US hospitals. The interval 2009-2011 was selected as ICD-9-CM code 277.88 for TLS was only introduced from the year 2009 onwards. Univariate and multivariate logistic regression were used to determine the independent predictors of in-hospital mortality. Data analysis was done using STATA version 13.0 (College Station, TX).ResultsAmong the 997 admissions (mean age ± SD 67.58±3.33, 62.6 % males, and 80.4 % white) with TLS, in-hospital mortality was 14.44 %. Based on the results of univariate analyses (table 1), we used obesity, coronary artery disease, cardiac dysrhythmias, acute kidney injury and sepsis in the final regression model. We found that cardiac dysrhythmias (OR 4.79; 95% CI, 1.67-13.77; p=0.004) and sepsis (OR 19.70; 95% CI, 5.33-72.78; p<0.001) were independent predictors of increased in-hospital mortality in patients with TLS. Although certain myeloid and lymphoid malignancies are associated with higher risk of tumor lysis syndrome, we did not observe any statistically significant increased risk of mortality with one specific type of malignancy over the other. Similarly, none of the demographic characteristics (age <40 vs ≥40, sex or race), or hospital characteristics (rural vs urban, teaching vs non-teaching, small vs large bed-size or geographic region) predicted increased in-hospital mortality in these patients.ConclusionIn this study of large national database, patients with TLS had an in-hospital mortality of 14.44 %. Independent predictors of in-hospital mortality were cardiac dysrhythmias and sepsis. Our findings might help physicians to identify sub-group of patients with TLS that are at increased risk of in-hospital mortality.Table 1Baseline characteristics of patients with tumor lysis syndrome according to in-hospital survivalCharacteristicsSurvivors (n=853)Non-survivors (n=144)pAge( in years)Mean68.40±3.0667.58±3.330.73Male sex62.165.80.69Race0.16White81.5273.54Black14.9822.8Hispanic2.270Others/unknown1.223.66Insurance status0.41Medicare65.5548.15Medicaid5.5613.34Private insurance24.8932.58Self-Pay0.652.99No charge0.630Other2.722.93Region0.13Northeast27.5937.74Midwest28.2312.92South31.3439.9West12.849.44Location/teaching status0.59Rural7.8710.16Urban nonteaching26.0133.52Urban teaching66.1256.32Bed-size0.84Small11.118.91Medium21.0424.55Large67.8566.54MalignanciesALL1.196.790.25AML2.346.990.29CLL27.8616.830.18CML1.853.190.68NHL36.3322.370.1HD0.5300.32Multiple Myeloma7.396.560.82Other hematologic malignancies38.6725.990.16Solid tumors35.8726.80.32Co-morbiditiesSmoking15.8921.870.46Obesity5.1600.005Dyslipidemia27.816.860.18Hypertension54.1749.190.63Diabetes mellitus27.8116.650.15PVD1.713.190.65CAD13.783.190.02AKI60.0679.540.03CKD28.8125.230.65Stroke0.6300.32Sepsis3.5831.810.003Cardiac dysrhythmias17.9643.420.04Acute CHF11.447.080.43AKI=Acute Kidney Injury; ALL=Acute Lymphoblastic Leukemia; AML=Acute Myelogenous Leukemia; CAD=Coronary Artery Disease; CHF=Congestive Heart Failure; CKD=Chronic Kidney Disease; CLL=Chronic Lymphocytic Leukemia; CML=Chronic Myelogenous Leukemia; HD=Hodgkin Disease; NHL=Non Hodgkin Lymphoma; PVD=Peripheral Vascular Disease DisclosuresNo relevant conflicts of interest to declare.

Utilization Trend and in-Hospital Complications of Autologous Hematopoietic Stem Cell Transplantation in Multiple Myeloma in the United States: 13 Years Perspective

Background: We aimed to explore utilization, complication and in-hospital mortality related to Autologous Hematopoietic Stem Cell Transplant (ASCT) in Multiple myeloma (MM) from 1998 to 2011 in United States.Methods: We used Nationwide Inpatient Sample (NIS) database to isolate multiple myeloma cases undergoing ASCT. Study included adults age >18 years. Patient and hospital demographics were extracted from NIS. Peri-procedural complications were calculated using ICD-9-CM codes. Hierarchical multivariate regression models were formulated to assess predictors of in-hospital mortality and complication.Results: Total of 6,957 (weighted-34,837) were available for analysis. Majority of patients were male (57%), white (57%) who presented to large bed size (78%),teaching (96%) hospital. Utilization of ASCT for MM increased from 5% in 1998 to 21.6% in 2011 (p<0.001). Despite temporal increase in mean age and comorbidites, mortality reduced (2.9 vs. 0.7, p<0.01) significantly from 1998 to 2011. In-hospital complications were common after ASCT with stomatitis (44.7%) being the most common followed by anemia requiring transfusion (28.5%), febrile neutropenia (16.5%) and bacteremia (15.0%). Mechanical ventilation and acute respiratory failure are the strongest predictors of in hospital mortality post ASCT followed by acute kidney injury,total Body irradiation (TBI) and bacteremia. Higher Charlson comorbidity index, female sex and TBI were associated with higher complication rates post ASCT.Conclusions: Utilization of ASCT for MM patients has increased significantly since 1998 and even though complications are very common in patients undergoing ASCT (77.4%), in-hospital mortality is rare (<2%) and has decreased significantly over the years secondary to decreased use of pre transplant TBI and better transplant care. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Changing Demographics in Laparoscopic Cholecystectomy Performed in the United States: Hospitalizations from 1998 to 2010

In the clinical experience at a community hospital, younger patients appear to be receiving more laparoscopic cholecystectomy (LC). The purpose of this study was to determine if LC is increasing in the younger patient population and if obesity is associated with the increase in LC. Patients undergoing LC were identified from the Healthcare Cost Utilization Project Nationwide Inpatient Sample database. There were 4,449,643 LCs from 1998 to 2010. Patients 15 to 24 years of age had the largest increase in LC (3.2%) and obesity (10.8%) from 1998 to 2010. In the 15- to 24-year age group, the following variables were associated with obesity: female, white, private payer, nonteaching hospital, urban location, southern region, large hospital bed size, and 3+ Charlson group, all P < 0.05. Additionally in the 15- to 24-year age group, median length of stay (nonobese 2 days vs obese 3 days) and median cost (nonobese $19,170 vs obese $22,802) were both increased (P < 0.001). The percentage of younger people having LC is increasing with highest increases in the obese population. The obese youth also have longer length of stay with an increase in hospital cost. These results suggest a rising disease burden associated with obesity among people ages 15 to 24 years. Gallstone disease burden will likely increase with the increase in prevalence of obesity and would add to healthcare economic burden.

Abstract T P239: Utilization and Outcomes of Ventriculostomy in Non-Traumatic Intracerebral Hemorrhage During Last Decade in United States

Background: Large studies describing recent trends in ventriculostomy utilization in non-traumatic ICH are lacking. Purpose: To describe trends, outcomes and predictors of ventriculostomy utilization in ICH. Study-design and Setting: Population based serial cross-sectional study of non-federal US hospitals from 2001-2010. Methods: Nationwide Inpatient Sample was searched for patients with primary diagnosis of ICH (ICD-9 code 431) undergoing ventriculostomy (ICD-9 code 02.2). Primary outcome measures were inpatient mortality and good functional outcomes as indicated by discharge to home. Resource utilization was measured by length of stay and inflation adjusted cost of care (2013 US dollar value). Logistic regression was used to identify independent predictors of ventriculostomy utilization. Population estimates were obtained by complex sample analysis taking into account the discharge weights, clustering and stratification used for sampling design. Results: A total of 652,738 ICH cases were included, of which 41,235 (6.3%) underwent ventriculostomy. The rate of ventriculostomy increased from 5.4% in 2001 to 7.5% in 2010 (trend p &lt;0.001). Predictors of higher ventriculostomy utilization were younger age, male gender, African-American ethnicity, lower Charlson comorbidity index, larger bed-size, urban location, teaching status, western US and more recent calendar year. Patient requiring ventriculostomy had higher inpatient mortality (40.2% vs. 28.1%, p&lt;0.001) and lower rate of good outcome (7.2% vs. 20.0%, p&lt;0.001). They also had longer length of stay (mean +/- SE: 19.2 +/- 0.3 vs. 7.2 +/- 0.1 days; p&lt;0.001) and incurred higher cost of care (USD 57,420 +/- 1,073 vs. 16,438 +/- 221; p&lt;0.001). Patient requiring early ventriculostomy (within 24 hours of admission) had increased mortality compared to those with late ventriculostomy (44.9% vs 32.8%, p&lt;0.001). Inpatient mortality in patients undergoing ventriculostomy decreased from 45.5% in 2001 to 37.7% in 2010 (trend p &lt;0.001). Conclusions: Patients requiring ventriculostomy in non-traumatic ICH have worse outcomes and higher resource utilization. Utilization of ventriculostomy for ICH increased and the mortality decreased in US hospitals during the last decade.