Longer Longer Length Of Stay Research Articles

The geriatric trauma hospitalist service: An analysis of a management strategy for injured older adults.

Management of geriatric trauma patients requires balancing chronic comorbidities with acute injuries. We developed a care model in which patients are managed by hospitalists with trauma-centered education and hypothesized that clinical outcomes would be similar to outcomes in patients primarily managed by trauma surgeons. This was a retrospective study of trauma patients aged ≥65 from January 2020 to December 2021. Groups were defined by admitting service: trauma surgery service (TSS) or geriatric trauma hospitalist service (GTHS). The primary outcome was in-hospital mortality. Regression analyses and inverse probability treatment weighted (IPTW) propensity score (PS) analyses were performed to determine the association between admitting service and outcomes. A total of 1004 patients were eligible for inclusion-580 GTHS and 424 TSS admissions. GTHS patients were older (82 vs. 74, p < 0.001), more likely to have suffered blunt trauma (99.5% vs. 95%, p < 0.001), more likely to have comorbidities (91.2% vs. 87%, p < 0.001), had higher Charlson Comorbidity Indexes (CCIs), and had lower median injury severity scores (9 vs. 13, p < 0.001). Rates of mortality, delirium, 30-day readmission, and overall complications were low and similar between groups. While TSS patients were likely to be discharged home, GTHS had more discharges to skilled nursing facilities and longer length of stay (LOS). On multivariable analysis adjusted for age, ISS, CCI, and sex, patients admitted to GTHS had lower odds of death with an odds ratio of 0.15 (95% confidence interval [CI] 0.02-0.75, p = 0.03) when compared to TSS. On IPTW PS analysis, patients admitted to GTHS had similar odds of death with an odds ratio of 0.3 (95% CI 0.06-1.6, p = 0.16). Protocolized admission criteria to a GTHS resulted in similar low mortality rates but longer LOS when compared to patients admitted to a TSS. This care model may inform other trauma centers in developing their strategies for managing the increasing volume of vulnerable injured older adults.

Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events.

To use machine learning to examine health equity and clinical outcomes in patients who experienced a nurse sensitive indicator (NSI) event, defined as a fall, a hospital-acquired pressure injury (HAPI) or a hospital-acquired infection (HAI). This was a retrospective observational study from a single academic hospital over six calendar years (2016-2021). Machine learning was used to examine patients with an NSI compared to those without. Inclusion criteria: all adult inpatient admissions (2016-2021). Three approaches were used to analyze the NSI group compared to the No-NSI group. In the univariate analysis, descriptive statistics, and absolute standardized differences (ASDs) were employed to compare the demographics and clinical variables of patients who experienced a NSI and those who did not experience any NSIs. For the multivariate analysis, a light grading boosting machine (LightGBM) model was utilized to comprehensively examine the relationships associated with the development of an NSI. Lastly, a simulation study was conducted to quantify the strength of associations obtained from the machine learning model. From 163,507 admissions, 4643 (2.8%) were associated with at least one NSI. The mean, standard deviation (SD) age was 59.5 (18.2) years, males comprised 82,397 (50.4%). Non-Hispanic White 84,760 (51.8%), non-Hispanic Black 8703 (5.3%), non-Hispanic Asian 23,368 (14.3%), non-Hispanic Other 14,284 (8.7%), and Hispanic 30,271 (18.5%). Race and ethnicity alone were not associated with occurrence of an NSI. The NSI group had a statistically significant longer length of stay (LOS), longer intensive care unit (ICU) LOS, and was more likely to have an emergency admission compared to the group without an NSI. The simulation study results demonstrated that likelihood of NSI was higher in patients admitted under the major diagnostic categories (MDC) associated with circulatory, digestive, kidney/urinary tract, nervous, and infectious and parasitic disease diagnoses. In this study, race/ethnicity was not associated with the risk of an NSI event. The risk of an NSI event was associated with emergency admission, longer LOS, longer ICU-LOS and certain MDCs (circulatory, digestive, kidney/urinary, nervous, infectious, and parasitic diagnoses). Machine learning methodologies provide a new mechanism to investigate NSI events through the lens of health equity/disparity. Understanding which patients are at higher risk for adverse outcomes can help hospitals improve nursing care and prevent NSI injury and harm.

Abstract 16506: Effect of COVID-19 on Outcomes of Patients Hospitalized With Takotsubo Cardiomyopathy

Introduction: Takotsubo Cardiomyopathy (TCM), commonly known as stress cardiomyopathy, is a condition characterized by the abrupt occurrence of acute left ventricular dysfunction, triggered by a variety of physical and psychosocial factors. The influence of COVID-19 on the outcomes of TCM hospitalizations remains relatively understudied. Thus, our objective was to investigate the impact of COVID-19 (COVID) on the outcomes of individuals hospitalized with TCM. Methods: The 2019-2020 National Inpatient Sample (NIS) was analyzed to identify adult hospitalizations admitted for TCM with a concurrent diagnosis of COVID-19 using International Classification of Disease 10 Clinical Modification (ICD-10-CM) codes. We compared baseline characteristics using T-test and Chi-square for continuous and categorical variables, respectively and multivariate regression analysis was used to adjust for potential confounders. Results: Out of the 41,324 TCM hospitalizations, 1,665 had a concurrent COVID infection. Hospitalizations with TCM and COVID had statistically significant difference in mortality (adjusted Odds Ratio (aOR) 2.30; Confidence Interval [CI] 1.2-4.5, p = 0.01), longer length of stay (LOS) 4.1 days (CI 2.8-5.5, p &lt; 0.001), and higher mean total hospital charges (THC) of $46,452 (CI 17,711-75203). Figure 1 shows the Forrest plot for multivariate analysis of in-hospital morbidities when adjusted for patient demographics, comorbidities and hospital characteristics. Conclusions: Patients hospitalized for TCM with concurrent COVID 19 infection had increased in-hospital mortality, longer LOS, higher THC and increased odds of cardiogenic shock, cardiac arrest, acute kidney injury (AKI), use of mechanical ventilation and use of vasopressor support.

Patients Who Have Pre-Existing Atrial Fibrillation Require Increased Postoperative Care Following Total Joint Arthroplasty

BackgroundApproximately 9% of total joint arthroplasty (TJA) patients have pre-existing atrial fibrillation (AF). This study examined the effect of pre-existing AF on TJA outcomes. MethodsWe conducted a 1:3 propensity match of 545 TJA patients who have pre-existing AF to TJA patients who do not have AF at a tertiary care center between January 1st, 2012, and January 1st, 2021. Bivariate and multivariate regressions were performed. Changes over time were evaluated. ResultsPatients undergoing total knee arthroplasty (TKA) who have pre-existing AF, experienced more post-operative AFs (P < .001), acute kidney injuries (P = .026), post-operative complications (POC) (P < .001), and 30-day readmissions (P = .036). Patients undergoing total hip arthroplasty (THA) who have pre-existing AF experienced more post-operative AFs (P < .001), pulmonary embolisms (P < .001), increased estimated blood losses (P = .007), more blood transfusions (P = .002), more POCs (P < .001), and longer lengths of stay (LOS) (P < .002). Over time, POC and LOS decreased in both groups, but remained increased in TJA patients who have pre-existing AF. Multivariate analyses of TKA patients showed an increased odds ratio (OR) of any POCs (P < .001), while THA patients had an increased OR of any POCs (P = .01), and LOS (P = .002). ConclusionPatients who have pre-existing AF undergoing TJA have more POCs. TKA patients have more readmissions. THA patients have longer LOS. These findings demonstrate the importance of enhanced peri-operative medical management in patients who have pre-existing AF undergoing TJA.

Degenerative spinal conditions requiring emergency surgery: an evolving crisis in a publicly funded health care system.

Surgery for degenerative spine pathologies is typically performed on a scheduled basis; however, worsening symptoms may warrant emergency surgery. An increasing number of patients requiring emergency surgery has been observed (22.6% in 2006 to 34.8% in 2019). We sought to compare the outcomes of patients who received scheduled surgery and those who required emergency surgery. All patients treated between Jan. 1, 2006, and Dec. 31, 2019, were included. Retrospective comparisons were made between patients who were scheduled (elective) for surgery and those requiring emergency surgery, patients who were scheduled for surgery and those who decompensated while on the surgical waitlist and patients who presented as de novo emergencies and those who decompensated while on the surgical waitlist. Among the 6217 patients with degenerative pathologies, 4654 (74.9%) patients were scheduled (elective) for surgery and 1563 (25.1%) were patients requiring emergency surgery. Compared with patients who were scheduled, patients requiring emergency surgery had a longer length of stay (LOS) in hospital (5.1 d, interquartile range [IQR] 2.7-11.2 v. 3.6 d, IQR 1.3-6.4, p < 0.001) and lower rate of home discharge (78.6% v. 94.2%, p < 0.001). Patients requiring emergency surgery were 1.34 times more likely to have any adverse events (95% confidence interval [CI] 1.06-1.68, p = 0.01). When compared with patients who were scheduled for surgery, those who decompensated while on the surgical waitlist had longer LOS (7.0 d, IQR 3.3-15.0 v. 3.6 d, IQR 1.3-6.4, p < 0.001), less home discharge (77.6% v. 94.2%, p < 0.001) and were 2.5 times more likely to have any adverse events (95% CI 1.5-4.1, p < 0.001). Patients who decompensated had a 2.1 times higher risk of having any adverse events than patients who presented as de novo emergencies (95% CI 1.2-3.6, p < 0.001). We observed worse perioperative outcomes for patients requiring emergency surgery for degenerative spinal conditions than for patients who were scheduled for surgery. Patients who decompensated while on the surgical waitlist had the worst outcomes.

Determinants of clinical outcome and length of stay in acute care forensic psychiatry units

Criminological and sociodemographic variables, such as previous criminal convictions, increased risk of violence, early onset of mental disorder, antisocial personality, psychosis and low social support, have all been related to longer length of stay (LoS) and poorer outcome in long stay forensic services. The factors impacting on LoS and clinical response in acute care specialized units are poorly documented. To address this issue, we examined the psychiatric records of all cases admitted between January 1st and December 31th 2020 in the sole acute ward for detained persons located in the central prison of the Geneva County, Switzerland. Information on judicial status included pre-trial versus sentence execution, previous incarcerations, and age of the first incarceration. Sociodemographic data included age, gender, marital status, and education attainment. Previous inpatient stays prior to incarceration were recorded. All of the ICD-10 clinical diagnoses were made by two independent, board-certified psychiatrists blind to the scope of the study. The standardized assessment was based on the HoNOS (Health of Nation Outcome Scales) at admission and discharge, HONOS-secure at admission, HCR-20 (Historical Clinical Risk 20) version 2, PCL-R (Psychopathy Checklist Revised), and SAPROF (Structured Assessment of Protective Factors). Stepwise forward multiple linear regression models predicting the LoS and delta HONOS respectively were built with the above mentioned parameters. The selected variables were then used in univariate and multivariable regression models. Higher HCR-scores (mainly on clinical items), and longer LoS were related to higher delta HONOS scores. In contrast, cases in pre-trial detention showed a worst clinical outcome. In multivariable models, all three variables remained independent predictors of the clinical outcome and explained 30.7% of its variance. Only education and diagnosis of borderline personality were related to the LoS and explained 12.6% of its variance in multivariable models. Our results suggest that the use of acute wards specialized in forensic psychiatry are mainly useful for patients with prior inpatient care experience, and higher violence risk during sentence execution. In contrast, they seem to be less performant for persons in pre-trial detention that could benefit from less restrictive clinical settings.

The Association of Metabolic Syndrome on Complications and Implant Survivorship in Primary Total Knee Arthroplasty in Morbidly Obese Patients

BackgroundMetabolic syndrome (MetS) includes interrelated conditions such as insulin resistance, abdominal obesity, hypertension, and dyslipidemia. This study sought to determine the association of MetS in morbidly obese patients (body mass index >40) on complications and clinical outcomes after primary total knee arthroplasty (TKA). MethodsA retrospective review was performed to include all morbidly obese patients who underwent primary elective TKA for osteoarthritis at a single academic institution. Patients who did and did not have MetS were propensity-matched 1:1 based on baseline characteristics. A total of 391 patients who did and 935 who did not have MetS were included having a mean body mass index of 44.2 (range, 40.0 to 68.9). ResultsThe MetS patients had longer lengths of stay (LOS) (3.5 ± 2.4 versus 3.0 ± 1.5 days, P = .001) and were more likely to be discharged to skilled nursing facilities (23.8 versus 15.3%, P = .007). At 90 days postoperatively, major (P = .756) and minor (P = .652) complication rates and readmissions (P = .359) were similar. Revision rates as well as improvements in KOOS-JR, and VR-12 mental and physical component scores from preoperative to 1 year (P = .856, P = .524, and P = .727, respectively) postoperatively did not significantly differ between groups. MetS and non-MetS patients had similar 5-year freedom from all-cause revision (90.2 versus 94.2%, P = .791). ConclusionMorbidly obese patients who have MetS had longer LOS and higher discharges to skilled nursing facilities. The 90-day complications, readmissions, revision rates, and patient-reported outcomes were similar, suggesting that resource allocation should be focused on perioperative protocols that can help optimize LOS and discharge dispositions in morbidly obese MetS patients undergoing TKA. Level of evidenceIII.

2005. Direct Hospitalization Costs Associated with Resistant and Susceptible Salmonella and Shigella Infections in the United States — 2012–2019

Abstract Background Foodborne illnesses cost ∼$90 billion in the United States annually. Antibiotic-resistant infections may be more difficult to treat and can be associated with severe outcomes, leading to higher costs and longer length of stay (LOS). We described LOS and costs for hospital admissions for Salmonella and Shigella infections by resistance status. Methods We reviewed all inpatient admissions from ∼300 hospitals in the Premier Healthcare database during 2012–2019 and included records with culture-confirmed nontyphoidal Salmonella (NTS), typhoidal Salmonella (serotypes Typhi and Paratyphi A, B, and C), or Shigella. We classified infections as resistant if laboratory testing found resistance to ≥1 drug in the clinically important antibiotic categories (fluoroquinolones, macrolides, penicillins, folate pathway antagonists, or third-generation cephalosporins) or susceptible otherwise. We used the Wilcoxon rank sum test to assess difference in median LOS and cost of patient hospitalization for resistant vs. susceptible infections by pathogen type. Results Of 4,168 persons hospitalized, about half (n=2,129, 51%) were female; median age was 52 [IQR: 26‒68] years; 29% (n=1,217) of infections were resistant. For NTS infections, median LOS was 4 [IQR: 3‒7] days for resistant and 4 [IQR: 3‒6] (p=0.04) for susceptible; for typhoidal Salmonella, 6 [IQR: 5‒8] for resistant and 5 [IQR: 3‒8] for susceptible (p=0.15); and for Shigella, 3 [IQR: 2‒4] for both (p=0.09). Median costs were highest for typhoidal Salmonella ($12,577 resistant vs. $9,238 susceptible; p=0.21), followed by NTS ($7,179 vs $6,421, p=0.01) and Shigella ($4,975 vs $5,335; p=0.26). Conclusion Hospitalization costs were higher for patients with some resistant infections. Longer LOS may contribute to higher costs; however, it is not clear whether other pathogen or patient factors (e.g., comorbidities) also contributed. Additional data and adjusted analyses may provide insight into reasons for the cost difference. If resistant infections are shown to be the cause, our findings support that public health interventions to limit the spread of resistant infections could reduce costs. Disclosures All Authors: No reported disclosures.

Abstract 12160: Sex Differences in Outcomes of Percutaneous Coronary Intervention in Octogenarians: A Retrospective Cohort Study From National Inpatient Sample 2016-2019

Introduction: The role of sex-based differences in the outcomes after principal percutaneous coronary intervention (PCI) in octogenarians is not well studied. Hypothesis: There are no differences in outcomes of PCI in octogenarians based on sex. Methods and Results: From 2016 to 2019, 37,147 hospitalizations (unweighted sample) for principal PCI procedures were identified. Among the principal PCI procedures performed, 44.9% (n = 16,660) were performed in females, and 55.2% (n = 20,487) in males (p &lt; 0.001), 82.4% in Whites, 5.4% in Blacks, 6.4% in Hispanics, and 2.6% in Asians. 20,986 (56.5%) principal PCI hospitalizations had a Charlson comorbidity index (CCI) of three or higher. The mean age for Octogenarians was 83.6 ± 2.7 years. Compared to males, the females were slightly older (mean age: 83.8 vs. 83.5; p &lt; 0.001), had higher prevalence of diabetes mellitus (20.5% vs 18%, p&lt;0.001) and lower Charlson comorbidity index (CCI) of three or higher (53.6% vs. 58.9%, p &lt;0.001). Females had higher incidence of cardiogenic shock (4.9% vs 4.2%, p=0.002), higher in-hospital mortality (4% vs 3%, p&lt;0.001) and longer length of stay (LOS) (4.4 days vs 4.1 days, p&lt;0.001). Multivariate regression analysis showed that, compared to males, females had a significantly higher odds of in-hospital mortality (aOR: 1.23; 95% CI: 1.10, 1.37; p &lt;0.001) and cardiogenic shock (aOR: 1.17; 95% CI: 1.06, 1.30; p=0.002) after controlling for age, race, hospital region, hospital teaching status, income, insurance provider, and CCI. From 2016-2019, in octogenarians, the annual incidence of principal PCI hospitalizations increased from 127 per 100,000 hospitalizations in 2016 to 137 per 100,000 hospitalizations in 2019, p&lt;0.001. Conclusions: The incidence of PCI done in octogenarians is rising every year. Females have an increased likelihood of in-hospital mortality, longer LOS, and cardiogenic shock.

Current status of perioperative temporary mechanical circulatory support during cardiac surgery.

We sought to determine utilization and outcomes of perioperative temporary mechanical circulatory support (tMCS) in the current practice of cardiac surgery. tMCS is an evolving adjunct to cardiac surgery not fully characterized in contemporary practice. Using the nationwide inpatient sample we retrospectively analyzed hospital discharge data between January 1, 2016 and December 31, 2019. ICD-10-CM procedure codes were used to identify and divide patient hospitalizations into those who had preoperative tMCS (pre-tMCS) versus tMCS instituted the day of surgery or afterwards (sd/post-tMCS). In all, 1,383,520 hospitalizations met inclusion criteria. 86,445 (6.25%) had tMCS. tMCS was utilized in 8.74% of coronary artery bypass grafting(CABG), 2.58% of isolated valve, and 9.71% of valve/CABG;operations.29,325 (33.9%) had pre-tMCS while 57,120 (66.1%) had sd/post-tMCS. The use of tMCS was associated with greater inpatient mortality (15.66% vs. 1.53%, p < .001), longer length of stay (LOS) (14.4 vs. 8.5 days, p < .001), and higher mean inflation-adjusted costs ($93,040 ± 1038 vs. $51,358 ± 296, p < .001) compared to no use. Inpatient mortality (5.98% vs. 20.63%, p < .001), LOS (13.87 vs. 14.68, p < .001), and cost ($82,621 ± 1152 SEM vs. $98,381 ± 1242) were all significantly lower with pre-tMCS compared to sd/post tMCS. When analyzed separately, mortality was higher with later utilization of tMCS (5.98% pre, 17.1% sd, and 49.05% postsurgical date insertion, p < .001). Perioperative tMCS is utilized in 6.25% of modern cardiac surgery, with two-thirds of cases instituted on the day of surgery or afterwards. The use of tMCS is associated with significantly higher mortality, longer LOS, and higher costs. Among patients undergoing tMCS, earlier utilization is associated with better outcomes.

BMI Change and Outcomes in Lung Transplant Recipients

Purpose Lung transplantation is a lifesaving therapy in patients with advanced lung disease. A body mass index (BMI) >30 is associated with worse outcomes after lung transplantation. Therefore, a BMI above 30 is considered a relative contraindication for lung transplantation in many centers. However, it is not clear how BMI changes after lung transplantation affects outcomes. Here we investigated how BMI changes after lung transplantation affect outcomes of lung transplant recipients. Methods We retrospectively assessed BMI and several post-transplant outcomes in 118 consecutive lung transplant recipients. The data was analyzed using R 4.0.2 (The R Foundation for Statistical Computing http://www.R-project.org). Packages Performance Analytics and ggplot2 were used in addition to core R. We evaluated impact of BMI change on mortality by running a Wilcoxon Sum-Rank test. We also did regression analysis controlling for impact of age, gender, race, type of lung transplant and length of stay. Results We evaluated 118 lung transplant recipients, 58 of whom were female. The average age was 56.06 years. Using traditional BMI categories, 7% of patients were underweight, 47% normal weight, 37% overweight, and 9% obese. Decrease in BMI of 2 or more points at 6 months after lung transplant was associated with increase mortality with odds ratio of death 5.13 and p=0.014. This effect was preserved when controlled for age, length of stay, gender, race, and type of transplant (p=0.02534). Interestingly, longer length of stay (LOS) was also associated with increased mortality independent from change in BMI, age, gender, race and type of transplant (p=0.00316). Conclusion A rather large proportion of lung transplant candidates are overweight by BMI criteria. A higher BMI was associated with a longer LOS after transplant and longer length of stay was associated with increased mortality. This effect was independent from change in age, gender, race and type of lung transplant. Patients who lost weight resulting in >2 points decrease in BMI at 6 months post-transplant also had increased mortality. This effect was independent from age, gender, race, length of stay and type of lung transplant. Larger studies are needed to confirm these findings and better understand the impact of weight change on outcomes after lung transplant. Lung transplantation is a lifesaving therapy in patients with advanced lung disease. A body mass index (BMI) >30 is associated with worse outcomes after lung transplantation. Therefore, a BMI above 30 is considered a relative contraindication for lung transplantation in many centers. However, it is not clear how BMI changes after lung transplantation affects outcomes. Here we investigated how BMI changes after lung transplantation affect outcomes of lung transplant recipients. We retrospectively assessed BMI and several post-transplant outcomes in 118 consecutive lung transplant recipients. The data was analyzed using R 4.0.2 (The R Foundation for Statistical Computing http://www.R-project.org). Packages Performance Analytics and ggplot2 were used in addition to core R. We evaluated impact of BMI change on mortality by running a Wilcoxon Sum-Rank test. We also did regression analysis controlling for impact of age, gender, race, type of lung transplant and length of stay. We evaluated 118 lung transplant recipients, 58 of whom were female. The average age was 56.06 years. Using traditional BMI categories, 7% of patients were underweight, 47% normal weight, 37% overweight, and 9% obese. Decrease in BMI of 2 or more points at 6 months after lung transplant was associated with increase mortality with odds ratio of death 5.13 and p=0.014. This effect was preserved when controlled for age, length of stay, gender, race, and type of transplant (p=0.02534). Interestingly, longer length of stay (LOS) was also associated with increased mortality independent from change in BMI, age, gender, race and type of transplant (p=0.00316). A rather large proportion of lung transplant candidates are overweight by BMI criteria. A higher BMI was associated with a longer LOS after transplant and longer length of stay was associated with increased mortality. This effect was independent from change in age, gender, race and type of lung transplant. Patients who lost weight resulting in >2 points decrease in BMI at 6 months post-transplant also had increased mortality. This effect was independent from age, gender, race, length of stay and type of lung transplant. Larger studies are needed to confirm these findings and better understand the impact of weight change on outcomes after lung transplant.

Different combinations of the GLIM criteria for patients awaiting a liver transplant: Poor performance for malnutrition diagnosis but a potentially useful prognostic tool

Studies using the Global Leadership Initiative on Malnutrition (GLIM) criteria for patients with liver cirrhosis are limited. This study aimed to assess the impact of malnutrition according to the GLIM criteria on the outcomes of patients awaiting a liver transplant (LTx) and compare these criteria with Subjective Global Assessment (SGA). This retrospective observational study included adult patients awaiting LTx. Patient clinical data, nutritional status according to various tools including SGA, and resting energy expenditure were assessed. The distinct phenotypic and etiologic criteria provided 36 different GLIM combinations. The GLIM criteria and SGA were compared using the kappa coefficient. The variables associated with mortality before and after the LTx and with a longer length of stay (LOS) after LTx (≥18 days) were assessed by Cox regression and logistic regression analyses, respectively. A total of 152 patients were included [median age 52.0 (interquartile range: 46.5-59.5) years; 66.4% men; 63.2% malnourished according to SGA]. The prevalence of malnutrition according to the GLIM criteria ranged from 0.7% to 30.9%. The majority of the GLIM combinations exhibited poor agreement with SGA. Independent predictors of mortality before and after LTx were presence of ascites or edema (p=0.011; HR:2.58; CI95%:1.24-5.36), GLIM 32 (PA-phase angle+MELD) (p=0.026; HR:2.08; CI95%:1.09-3.97), GLIM 33 (PA+MELD-Na≥12) (p=0.018; HR:2.17; CI95%:1.14-4.13), and GLIM 34 (PA+Child-Pugh) (p=0.043; HR:1.96; CI95%:1.02-3.77). Malnutrition according to GLIM 28 (handgrip strength+Child-Pugh) was independently associated with a longer LOS (p=0.029; OR:7.21; CI95%:1.22-42.50). The majority of GLIM combinations had poor agreement with SGA, and 4 of the 36 GLIM combinations were independently associated with adverse outcomes.

Unmanaged Pharmacogenomic and Drug Interaction Risk Associations with Hospital Length of Stay among Medicare Advantage Members with COVID-19: A Retrospective Cohort Study.

Unmanaged pharmacogenomic and drug interaction risk can lengthen hospitalization and may have influenced the severe health outcomes seen in some COVID-19 patients. To determine if unmanaged pharmacogenomic and drug interaction risks were associated with longer lengths of stay (LOS) among patients hospitalized with COVID-19, we retrospectively reviewed medical and pharmacy claims from 6025 Medicare Advantage members hospitalized with COVID-19. Patients with a moderate or high pharmacogenetic interaction probability (PIP), which indicates the likelihood that testing would identify one or more clinically actionable gene–drug or gene–drug–drug interactions, were hospitalized for 9% (CI: 4–15%; p < 0.001) and 16% longer (CI: 8–24%; p < 0.001), respectively, compared to those with low PIP. Risk adjustment factor (RAF) score, a commonly used measure of disease burden, was not associated with LOS. High PIP was significantly associated with 12–22% longer LOS compared to low PIP in patients with hypertension, hyperlipidemia, diabetes, or chronic obstructive pulmonary disease (COPD). A greater drug–drug interaction risk was associated with 10% longer LOS among patients with two or three chronic conditions. Thus, unmanaged pharmacogenomic risk was associated with longer LOS in these patients and managing this risk has the potential to reduce LOS in severely ill patients, especially those with chronic conditions.

Demographics, comorbidities, and outcomes among young and middle-aged COVID-19 patients in Saudi Arabia

The impact of different sociodemographic and clinical characteristics on the COVID-19-related morbidity and mortality rates have been studied extensively around the world; however, there is a dearth of data on the impact of different clinical and sociodemographic variables on the COVID-19-related outcomes in Saudi Arabia. This study aimed to identify those at high risk of worse clinical outcomes, such as hospitalization and longer length of stay (LOS) among young and middle-aged adults (18 to 55 years). In this questionnaire-based cross-sectional study, 706 patients with real-time polymerase chain reaction (RT-PCR) confirmed COVID-19 infection were interviewed. Patients’ demographic characteristics, dietary habits, medical history, and lifestyle choices were collected through phone interviews. Patients with chronic health conditions, such as diabetes and hypertension, reported a higher rate of hospitalization, ICU admission, oxygen-support needs, and a longer period of recovery and LOS. Multiple logistic regression showed that diabetes, hypertension, and pulmonary disease (e.g., asthma and chronic obstructive pulmonary disease (COPD)) were associated with a higher risk of hospitalization and longer LOS. Multiple logistic regression showed that symptoms of breathlessness, loss of smell and/or taste, diarrhea, and cough were associated with a longer recovery period. Similarly, breathlessness, vomiting, and diarrhea were associated with higher rates of hospitalization. The findings of this study confirm the similarity of the factors associated with worse clinical outcomes across the world. Future studies should use more robust designs to investigate the impact of different therapies on the COVID-19-related morbidity and mortality in Saudi Arabia.

English

BACKGROUND Comorbidity in elderly has negative impact on physiological and cognitive functions, the prevalence of which is increasing. Management of multiple comorbidities has resulted in polypharmacy in elderly. Comorbidity Polypharmacy Score (CPS) is a clinical tool to quantify severity of comorbidities using polypharmacy as surrogate for intensity of treatment required to adequately manage comorbidities. We wanted to evaluate CPS as predictor of post-operative outcomes in geriatric patients undergoing elective surgeries. METHODS A prospective observational study was conducted in a tertiary care centre among elderly patients (more than 65 years) undergoing elective surgeries satisfying inclusion criteria. Calculated sample size was 250. CPS was calculated by assigning one point to each comorbidity and medication taken and sum calculated was categorised. Primary outcomes were defined by hospital length of stay and Barthel index at day 3 and day 5. RESULTS We found moderate positive correlation using Pearson Correlation with CPS and Barthel index at day 3 (p - value = 0.0024, correlation coefficient = - 0.191) and day 5 (p - value = 0.0013, correlation coefficient= -0.202). ANOVA test was applied to compare age with Barthel index at day 3 (p - value = 0.0005) and day 5 (p - value &lt; 0.0001) which was statistically significant. Advanced age was not associated with longer Length of Stay (LOS) (p - value = 0.32). CPS was also not associated with longer LOS (p - value = 0.821). CONCLUSIONS CPS is an easy to measure tool for the evaluation of elderly surgical patients. CPS can be used to predict recovery in terms of activities of daily living (ADL) after surgery thereby preparing patient and family to cope up with stress of surgery and its financial and psychological outcomes. KEYWORDS Geriatric Anaesthesia, Comorbidity-Polypharmacy Score, Activities of Daily Living, Length of Stay, Barthel Index

Frailty and length of stay in older adults with blunt injury in a national multicentre prospective cohort study.

BackgroundPatients suffering moderate or severe injury after low falls have higher readmission and long-term mortality rates compared to patients injured by high-velocity mechanisms such as motor vehicle accidents. We hypothesize that this is due to higher pre-injury frailty in low-fall patients, and present baseline patient and frailty demographics of a prospective cohort of moderate and severely injured older patients. Our second hypothesis was that frailty was associated with longer length of stay (LOS) at index admission.MethodsThis is a prospective, nation-wide, multi-center cohort study of Singaporean residents aged ≥55 years admitted for ≥48 hours after blunt injury with an injury severity score or new injury severity score ≥10, or an Organ Injury Scale ≥3, in public hospitals from 2016–2018. Demographics, mechanism of injury and frailty were recorded and analysed by Chi-square, or Kruskal-Wallis as appropriate.Results218 participants met criteria and survived the index admission. Low fall patients had the highest proportion of frailty (44, 27.3%), followed by higher level fallers (3, 21.4%) and motor vehicle accidents (1, 2.3%) (p < .01). Injury severity, extreme age, and surgery were independently associated with longer LOS. Frail patients were paradoxically noted to have shorter LOS (p < .05).ConclusionPatients sustaining moderate or severe injury after low falls are more likely to be frail compared to patients injured after higher-velocity mechanisms. However, this did not translate into longer adjusted LOS in hospital at index admission.

The multidimensional prognostic index (MPI) for the prognostic stratification of older inpatients with COVID-19: A multicenter prospective observational cohort study

BackgroundThe topic of prognosis in COVID-19 research may be important in adopting appropriate clinical decisions. Multidimensional prognostic index (MPI) is a frailty assessment tool widely used for stratifying prognosis in older people, but data regarding inpatients, affected by COVID-19, are not available. ObjectivesTo evaluate whether MPI can predict in-hospital mortality and the admission to intensive care unit (ICU) in older inpatients hospitalized for COVID-19 infection. MethodsIn this longitudinal, Italian, multi-center study, older patients with COVID-19 were included. MPI was calculated using eight different domains typical of comprehensive geriatric assessment and categorized in three groups (MPI 1 ≤ 0.33, MPI 2 0.34–0.66, MPI 3 > 0.66). A multivariable Cox's regression analysis was used reporting the results as hazard ratios (HRs) with 95% confidence intervals (CIs). Results227 older patients hospitalized for SARS-CoV-2 infection were enrolled (mean age: 80.5 years, 59% females). Inpatients in the MPI 3 were subjected less frequently than those in the MPI 1 to non-invasive ventilation (NIV). In the multivariable analysis, people in MPI 3 experienced a higher risk of in hospital mortality (HR = 6.30, 95%CI: 1.44–27.61), compared to MPI 1. The accuracy of MPI in predicting in hospital mortality was good (Area Under the Curve (AUC) = 0.76, 95%CI: 0.68–0.83). People in MPI 3 experienced a significant longer length of stay (LOS) in hospital compared to other participants. No association between MPI and ICU admission was found. ConclusionsFrailty- as assessed by high MPI score - was associated with a significant higher risk of in-hospital mortality, longer LOS, and lower use NIV, whilst the association with ICU admission was not significant. These findings suggest that prognostic stratification by using the MPI could be useful in clinical decision making in older inpatients affected by COVID-19.

Estimated length of stay calculated by “diagnosis-related groups” in patients with prostate cancer: a retrospective analysis

INTRODUCTION: To evaluate whether the presence of bone metastasis in hospitalized patients with prostate cancer (PCa) is associated with a longer length of stay (LOS) when compared to LOS estimated by diagnosis-related groups (DRG). METHODS: We performed a retrospective analysis of 86 admissions of patients with PCa at our facility in 2018-2019. Admissions were divided into two groups based on actual LOS and LOS estimated by DRG: group 1 (actual LOS≥DRG-LOS) and group 2 (actual LOS<DRG-LOS). The association of bone metastasis and other variables with increased LOS was evaluated by logistic regression with univariable and multivariable analysis, controlling baseline patient characteristics. RESULTS: Longer LOS was not associated with baseline characteristics (age, body mass index, and presence of comorbidities), but was significantly associated with type of admission and ICU (intensive care unit) admission during hospitalization (p<0.05). Bone metastasis was observed in 28 (68.3%) of group 2 admissions and was independently associated with increased LOS (group 2) on univariable and multivariable analysis (OR=4.76, 95% CI=1.91-11.8, p=0.001; OR=3.48, 95% CI=1.08-11.2, p=0.03, respectively). CONCLUSION: Among clinical or surgical admissions of patients with PCa over a 1-year period, presence of bone metastasis was independently associated with increased LOS when compared to LOS estimated by DRG. The presence of bone metastasis may be used to identify possible outliers not recognized by the DRG system.

The modern trauma pancreaticoduodenectomy for penetrating trauma: a propensity-matched analysis.

Trauma pancreaticoduodenectomy (TP) remains a challenging operation with morbidity and mortality rates as high as 80% and 50%. Many trauma surgeons consider it surgical dogma to avoid performing a TP during the index operation for patients with severe pancreatic or duodenal injuries. However, there is no modern analysis evaluating this belief. Therefore, we hypothesized no difference in risk of mortality between patients with severe pancreatic or duodenal injury undergoing a TP for penetrating trauma to propensity-matched controls undergoing laparotomy without TP. The Trauma Quality Improvement Program (2010–2016) was queried for adults with severe penetrating pancreatic or duodenal injuries undergoing laparotomy. A 1:2 propensity-matching including demographics/comorbidities, injury severity score, vitals on admission, Glasgow Coma Scale and concomitant injuries for laparotomy with or without TP was performed. Risk of mortality was reported using a univariable logistic regression model. Of 2182 patients with severe pancreatic or duodenal injuries undergoing laparotomy, 54 (2.5%) underwent TP and 2128 (97.5%) underwent laparotomy without TP. There were no differences in propensity-matching characteristics. Patients undergoing TP had a similar mortality rate (20.0% vs. 28.7%, p = 0.302) but a longer length of stay (LOS) (27.5 vs. 16.5 days, p = 0.017). The TP group had a similar associated risk of mortality (OR = 0.62, p = 0.302) but higher risk of major complications (OR 3.44, CI 1.35–17.47, p = 0.015). In appropriately selected penetrating trauma patients with severe pancreatic/duodenal injuries, TP is associated with a similar risk of mortality compared to laparotomy without TP. However, TP patients did have an increased associated risk of major complications and longer LOS.

Preoperative frailty predicts adverse short-term postoperative outcomes in patients treated with radical nephroureterectomy.

To investigate the effect of frailty on short-term postoperative outcomes and total hospital charges (THCs) in patients with non-metastatic upper urinary tract carcinoma, treated with radical nephroureterectomy (RNU). Within the National Inpatient Sample (NIS) database we identified 11 258 RNU patients (2000-2015). We used the Johns Hopkins frailty-indicator to stratify patients according to frailty status. Time trends and multivariable logistic, Poisson and linear regression models were applied. Overall, 1801 (16.0%) patients were frail, 4664 (41.4%) were older than 75 years and 1530 (13.6%) had Charlson comorbidity index ≥2. Rates of frail patients increased over time, from 7.3% to 24.9% (P < .001). Frail patients exhibited higher rates (all P < .05) of overall complications (62.6% vs 50.9%), in-hospital mortality (1.6% vs 1.0%), non-home-based discharge (22.7% vs 12.1%), longer length of stay (LOS) (6 vs 1 day) and higher THCs ($49 539 vs $39 644). Moreover, frailty independently predicted (all P < .05) overall complications (OR, 1.46), in-hospital mortality (OR, 1.52), non-home-based discharge (OR, 1.36), longer LOS (RR, 1.30) and higher THCs (RR, +$11 806). Preoperative frailty is important in RNU patients. One of four RNU patients is frail. Moreover, frailty predicts short-term postoperative complications, as well as longer LOS and higher THCs after RNU.