Longer Mean Length Of Stay Research Articles

Relationships between sex and in-hospital outcomes of patients with acute cardiogenic shock receiving mechanical circulatory support

BackgroundCardiovascular disease is the leading cause of mortality in women. Despite this there is a paucity of data on the impact of sex on utilization and outcomes of temporary mechanical circulatory support (tMCS) in patients hospitalized with Acute Myocardial Infarction (AMI) Cardiogenic Shock (CS). MethodsWe examined the 2016–2019 National Inpatient Sample database to identify cases of AMI-CS. Men were used as our control group, while women comprised our cohort. The primary outcome was in-hospital mortality. Secondary outcomes included the use of tMCS including; left ventricular assist device (LVAD) use, Impella use, and Intra-Aortic Balloon Pump (IABP) use, length of stay (LOS) and total hospitalization cost (THC). Multivariate linear and logistic regression models were used to adjust for confounders. ResultsAmong patients hospitalized for AMI (N = 2,622,939), 37.7 % were Female. A Female sex was associated with a higher inpatient mortality (adjusted OR [aOR] 1.06, p < 0.001), a lower likelihood of LVAD use (2.3 % vs. 2.9 % and p < 0.001), IABP use (3.0 % vs. 4.4 % and p < 0.001), Impella use (1.0 % vs. 1.5 % and p < 0.001), a longer mean LOS (4.4 vs 4.3 days and p < 0.001) and lower THC ($88,097 vs. $104,101, p < 0.001) compared to male patients for AMI-CS. ConclusionFemale patients admitted for AMI-CS were less likely to receive tMCS despite a higher mortality rate and a slightly longer LOS compared to male patients. Further studies are necessary to confirm these findings and elucidate clearer causality for such disparities.

Abstract 14181: Interhospital Transfer for Heart Failure in the United States: A Patient and Hospital-Level Analysis From GWTG-HF

Background: Cardiovascular diseases, particularly heart failure (HF), are common reasons for interhospital transfer (IHT) in the United States. IHT targets patients requiring a higher level of care, and has been associated with increased cost, length of stay (LOS), and mortality. We aim to describe the characteristics and outcomes of patients undergoing IHT, as well as variation in the use of IHT across hospitals. Methods: Patients hospitalized for HF who were admitted from another hospital were compared to those who were not within the Get With The Guidelines-Heart Failure registry between January 2015 and June 2022. Hospital characteristics were obtained from the 2018 American Hospital Association Survey. Clinical data from the receiving hospital were analyzed. Results: Overall, 662,575 patients across 622 hospitals (156,263 patients at 127 transplant centers; 19,852 patients at 55 rural sites) were included, of which 36,375 (5.5%) arrived as IHT. IHT patients were younger (70.0 vs 73.0 years), more male (58 vs 52%), white (72 vs 66%), and more often had private insurance (31% vs 27%). IHT patients had a lower median left ventricular ejection fraction (37 vs 45%), median blood pressure (130/74 vs 139/77 mmHg), and a longer mean LOS (6.3 vs 5.0 days). In a multivariable model, IHT patients had higher in-hospital mortality (OR 1.85, 95% CI 1.76-1.95), were less likely to discharge home (OR 0.79, 95% CI 0.77-0.81), and were more likely to be prescribed most guideline-directed therapies (Figure). Conclusions: More than 1 in 20 patients hospitalized for HF was transferred from another hospital. Sex, racial, economic, and geographic differences exist in which HF patients get transferred, and rates of IHT varied across hospitals. IHT was associated with higher mortality and longer LOS compared with non-transferred patients.

Abstract #1403761: The Impact of COVID-19 Infection on Diabetic Ketoacidosis Acidosis Hospitalization: A Nationwide Analysis

One of the potentially fatal consequences for diabetic patients is diabetic ketoacidosis acidosis (DKA), which is also linked to poor hospital outcomes. There is no much information in literature about COVID-19 and how it relates to other hospitalizations. The impact of COVID-19 on in-hospital mortality and other clinically relevant outcomes for DKA patients is being investigated for the first time in this study. Patients admitted with a primary diagnosis of DKA with or without a subsequent diagnosis of COVID-19 Infection were found in the National Inpatient Sample (NIS) Database 2020. Patients were divided into two groups: those who have COVID-19 and those who don't. Univariate and multivariate logistic regression models were utilized to account for frequent confounders and assess the risk of mortality and in-hospital outcomes between the two groups. The total of 110,130 DKA admissions were identified between Jan and Dec 2020. COVID-19 Infection was diagnosed in 2,504 patients (2.2%). The average age of the cohort sample was 35 years old, 51% were male, and 60% were white. The average length of stay (LOS) was 3 days, and the average total hospital charges were 33,132 US dollars. The total number of patients who died was 225 patients. When the two groups were compared, COVID-19 Infection was associated with an increased risk of in-hospital mortality among DKA patients (OR 5.3, 95% CI 1.7–15.9, p=0.003). COVID-19 patients had a higher risk of acute respiratory failure (OR 2.9, 95% CI 1.7–3.9, p< 0.001) and septic shock (OR 3.9, 95% CI 1.5–9.8, p=0.003). There was no significant difference between the COVID-19 and non-COVID-19 groups in the risk of acute coronary syndrome (OR 1.2, 95% CI 0.49–3, p=0.66), cardiac arrest (OR 2, 95% CI 0.5–7.9, p=0.31), hypokalemia (OR 1.14, 95% CI 0.92–1.4, p=0.214), deep vein thrombosis (OR 0.59, 95% CI 0.14–2.4, p=0.47), or pulmonary embolism (OR 3.6, 95% CI 0.84 – 15.4, p=0.083). COVID-19 patients had a longer mean LOS (4.2 vs 2.9 days, p< 0.001) and higher mean total hospital charges (41,216 vs 32,973 $, p=0.004). Patients admitted with DKA and concomitant COVID-19 infection found to have a higher risk of in-hospital mortality and worse hospital outcomes, particularly acute respiratory failure and septic shock. In comparison to non-COVID patients, COVID-19 patients have a longer mean LOS and a higher mean of total hospital charges.

S1449 Prior Bariatric Surgery and Labor/Delivery and Pregnancy Complications

S1449 Prior Bariatric Surgery and Labor/Delivery and Pregnancy Complications

Factors Associated With Increasing Length of Stay for Rheumatoid Arthritis Patients Undergoing Total Hip Arthroplasty and Total Knee Arthroplasty.

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are cost-effective procedures that decrease pain and improve health-related quality of life for patients with advanced symptomatic arthritis, including rheumatoid arthritis (RA). Patients with RA have a longer length of stay (LOS) after THA or TKA than patients with osteoarthritis, yet the factors contributing to LOS have not been investigated. Purpose: We sought to identify the factors contributing to LOS for patients with RA undergoing THA and TKA at a single tertiary care orthopedic specialty hospital. Methods: We retrospectively reviewed data from a prospectively collected cohort of 252 RA patients undergoing either THA or TKA. Demographics, RA characteristics, medications, serologies, and disease activity were collected preoperatively. Linear regression was performed to explore the relationship between LOS (log-transformed) and possible predictors. A multivariate model was constructed through backward selection using significant predictors from a univariate analysis. Results: Of the 252 patients with RA, 83% were women; they had a median disease duration of 14 years and moderate disease activity at the time of arthroplasty. We had LOS data on 240 (95%) of the cases. The mean LOS was 3.4 ± 1.5 days. The multivariate analysis revealed a longer LOS for RA patients who underwent TKA versus THA, were women versus men, required a blood transfusion, and took preoperative opioids. Conclusion: Our retrospective study found that increased postoperative LOS in RA patients undergoing THA or TKA was associated with factors both non-modifiable (type of surgery, sex) and modifiable (postoperative blood transfusion, preoperative opioid use). These findings suggest that preoperative optimization of the patient with RA might focus on improving anemia and reducing opioid use in efforts to shorten LOS. More rigorous study is warranted.

Severe Outcomes, Readmission, and Length of Stay Among COVID-19 Patients with Intellectual and Developmental Disabilities

ObjectivesThe aim of this study was to evaluate the association between intellectual and developmental disabilities (IDDs) and severe COVID-19 outcomes, 30-day readmission, and/or increased length of stay (LOS) using a large electronic administrative database. MethodsPatients hospitalized with COVID-19 were identified between March 2020 and June 2021 from more than 900 hospitals in the United States. IDDs included intellectual disability, cerebral palsy, Down syndrome, autism spectrum disorder (ASD), and other intellectual disabilities. Outcomes included intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), 30-day readmission, mortality, and LOS. ResultsAmong 643,765 patients with COVID-19, multivariate models showed that patients with any IDD were at a significantly greater risk of at least 1 severe outcome, 30-day readmission, or longer LOS than patients without any IDD. Compared with those without any IDD, patients with Down syndrome had the greatest odds of ICU admission (odds ratio [OR] and 95% confidence interval [CI]: 1.96 [1.73-2.21]), IMV (OR: 2.37 [2.07-2.70]), and mortality (OR: 2.33 [2.00-2.73]). Patients with ASD and those with Down syndrome both had over a 40% longer mean LOS. Patients with intellectual disabilities had a 23% (12-35%) increased odds of 30-day readmission. ConclusionsResults suggest that patients hospitalized with COVID-19 with IDD have a significantly increased risk of severe outcomes, 30-day readmission, and longer LOS.

Abstract 13638: Protein Calorie Malnutrition is an Adverse Prognostic Marker in Atrial Fibrillation Patients: An Analysis of the National Inpatient Sample Registry

Introduction: Protein Calorie Malnutrition (PCM) is not thought to be associated with atrial fibrillation (AF). Some research has stipulated that overweight AF patients may have a better prognosis than those with normal weight, however, the interaction between poor nutritional status and AF has not been well explored. Dyselectrolytemias secondary to malnutrition could confer a poor prognosis in AF patients. We aimed to assess the impact of PCM on outcomes in patients admitted with AF. Methods: A retrospective cohort study was conducted using the Nationwide Inpatient Sample from 2017. About 412,159 hospitalizations who had AF as their primary diagnosis were identified and stratified based on the presence of PCM using ICD-10 codes. Multivariate regression analysis was used to adjust for confounders and to analyze the variables. The selection of covariates was done with a univariate screen and literature review. Results: Out of the 412,159 hospitalized patients with AF, 11,590 individuals had PCM. In-hospital mortality in AF patients with PCM were significantly higher than those without (4.62% vs 0.77%); p&lt;0.0001. When adjusted for patient demographics, comorbidities, and hospital characteristics, AF patients with PCM had a higher risk of mortality (aOR=3.45, p&lt;0.0001), cardiac arrest (aOR=2.41, p&lt;0.0001), PE (aOR=2.06, p&lt;0.0001), sepsis (aOR=4.72, p&lt;0.0001), pneumonia (aOR=2.25, p&lt;0.0001), AKI (aOR=1.41, p&lt;0.0001), acute respiratory failure (ARF) (aOR=1.81, p=0.011), and being intubated (aOR=1.45, p=0.019). When adjusted similarly, AF patients with PCM had longer length of stay (LOS) by 2.76 days (mean LOS: 6.61 vs 3.25 days) (p&lt;0.0001) and an additional hospital cost (HC) of $18,373 (mean HC: $62,093 vs $39,934) (p&lt;0.0001). However, there was no difference in the risk of developing stroke (aOR=1.23, p=0.26) in AF patients with PCM. Conclusions: AF patients with PCM had worse outcomes in terms of in-hospital mortality, LOS, HC, cardiac arrest, PE, sepsis, pneumonia, AKI, ARF, and being intubated compared to those without PCM. This suggests that PCM is an adverse prognostic marker in this population. Current limitations include the underrepresentation of metabolic derangements due to inadequate coding within this administrative database.

A nationwide analysis of outcomes and healthcare utilization in HIV versus non-HIV patients with colon cancer.

3550 Background: The incidence and mortality of Colon cancer (CC) is reportedly similar in HIV and non-HIV populations with same screening guidelines. The pathogenesis of HIV-CC may be multifactorial; related to chronic inflammation from AIDS colopathy, 2-fold increase in risk of polyps, smoking, elevation in proinflammatory cytokines, decrease in adiponectin, activation of b-catenin signaling pathway all of which may promote neoplastic growth of colonic mucosa. With increasing survival in HIV due to effective antiretroviral therapy, non-AIDS defining cancers are rising as population ages. We attempted to compare demographics and outcomes of HIV and non-HIV-CC patients in a national database. Methods: Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) was queried to identify all HIV and non-HIV-CC admissions. The groups were compared for socio-demographic differences, medical comorbidities, inpatient mortality, length of stay (LOS) and hospital charges (THC). Secondary outcomes studied included rates of sepsis, septic shock (SS), Anemia, transfusions, GI bleeding, colostomy rates, Acute Kidney Injury (AKI) and protein energy malnutrition (PEM). Statistics were performed using t-test, univariate and multinomial logistic regression. Results: A total 895 HIV-CC and 514,840 non-HIV-CC admissions were identified. HIV-CC were younger (mean age 56.3 vs 67.3 years, p &lt; 0.001) with 76% &lt; 65 years old compared to 40% in non-HIV-CC. HIV-CC were more likely male (75.4% vs 50.5%, p &lt; 0.001), African Americans (AA) (43% vs 14%, p &lt; 0.001) and Hispanic (19% vs 9%, p &lt; 0.001), were more likely from lowest income quartile zip codes (44% vs 28%, p &lt; 0.001) from the Northeast region of US (27% vs 19%, p &lt; 0.001) and on Medicaid (30% vs 10%, p &lt; 0.001). HIV-CC had significantly lower rates of medical comorbidities (hypertension, diabetes, obesity, dyslipidemia, heart failure, all p &lt; 0.05) compared to non-HIV-CC. The odds of adjusted inpatient mortality were significantly lower in HIV-CC (aOR = 0.46 CI = 0.24-0.87, p = 0.018), however HIV-CC had longer mean LOS (8.17 vs 6.66 days, p &lt; 0.01) and higher mean THC ($88,305 vs $76,317, p = 0.051). Cancer pain and PEM were significantly higher in the HIV-CC group, but other secondary outcomes were similar. Conclusions: HIV-CC patients were significantly younger and minorities with significantly lower all-cause mortality compared to non-HIV-CC. The lower mortality may be explained by younger age, treatment of teaching hospitals for HIV-CC and lower incidence of medical comorbidities which may be driving mortality higher in non-HIV-CC. However, healthcare utilization of HIV-CC was higher with over $10 million in extra charges in 3 years compared to non-HIV-CC. The young age of HIV-CC compared to non-HIV suggests a need for studies to evaluate the role of starting colon-cancer screening at a younger age in the HIV population.

Resource Use by Hospital Type for Frequent Inpatient Pediatric Conditions.

Children's hospitals (CHs) deliver care to underserved, critically ill, and medically complex patients. However, non-CHs care for the majority of children with frequently occurring conditions. In this study, we aimed to examine resource use across hospitals where children receive care for frequent inpatient conditions. This was a cross-sectional, observational analysis of pediatric hospitalizations for 8 frequent inpatient conditions (pneumonia, asthma, bronchiolitis, mood disorders, appendicitis, epilepsy, skin and soft tissue infections, and fluid and electrolyte disorders) in the 2016 Kids' Inpatient Database. Primary outcomes were median length of stay (LOS) and median total cost. The primary independent variable was hospital type: nonchildren's, nonteaching; nonchildren's, teaching (NCT); and freestanding CHs. Multivariable linear regression was used to assess differences in mean LOS and costs. There were 354 456 pediatric discharges for frequent inpatient conditions. NCT hospitals cared for more than one-half of all frequent inpatient conditions. CHs and NCT hospitals cared for the majority of patients with higher illness severity and medical complexity. After controlling for patient and hospital factors, discharges for frequent inpatient conditions at CHs had 0.48% longer mean LOS and 61% greater costs compared with NCT hospitals (P < .01). CHs revealed higher estimated costs in caring for frequent inpatient conditions despite controlling for patient- and hospital-level factors but also cared for higher illness severity and medical complexity. Further research is warranted to explore whether we lack sufficient measures to control for patient-level factors and whether higher costs are justified by the specialized care at CHs.

How a Malnutrition Quality Improvement Initiative Furthers Malnutrition Measurement and Care: Results From a Hospital Learning Collaborative.

BackgroundMalnutrition in hospitalized patients can adversely affect health outcomes and increase the cost of care. Real‐world strategies are needed for prompt identification and treatment of patients at risk of malnutrition.ObjectivesThe aim of this quality improvement (QI) study was to measure the impact of a nutrition‐focused program on the malnutrition care processes of participating hospitals. Secondary objectives were to determine whether improvements in these nutrition‐related processes reduced hospital readmissions and length of stay (LOS) in patients ≥65 years.MethodsA group of 27 US hospitals (“The Collaborative”) implemented the Malnutrition Quality Improvement Initiative (MQii), as guided by a Malnutrition QI Toolkit and 4 electronic clinical quality measures (eCQMs), including (1) nutrition screening; (2) nutrition assessment following detection of malnutrition risk; (3) nutrition care plan for patients identified as malnourished after completed nutrition assessment; and (4) documentation of malnutrition diagnoses. Multivariate analyses identified the variables best correlated with patient outcomes.ResultsImprovements were observed for all 4 eCQMs. The greatest improvements were achieved as a result of timely nutrition assessment (P = .06) and malnutrition diagnosis (P = .02). Patients ≥65 years with a malnutrition diagnosis and nutrition care plan had a 24% lower likelihood of 30‐day readmission but a longer mean LOS than did those without a care plan.ConclusionsIn this study, the implementation of MQii practices significantly improved the identification of malnutrition. The prompt identification and treatment of patients at malnutrition risk can improve patient care and health, as well as reduce costly readmissions.

Retrospective study of inpatient diabetes management service, length of stay and 30-day readmission rate of patients with diabetes at a community hospital

ABSTRACTBackground: Hospitalized patients with diabetes are at risk of complications and longer length of stay (LOS). Inpatient Diabetes Management Services (IDMS) are known to be beneficial; however, their impact on patient care measures in community, non-teaching hospitals, is unknown.Objectives: To evaluate whether co-managing patients with diabetes by the IDMS team reduces LOS and 30-day readmission rate (30DR).Methods: This retrospective quality improvement cohort study analyzed LOS and 30DR among patients with diabetes admitted to a community hospital. The IDMS medical team consisted of an endocrinologist, nurse practitioner, and diabetes educator. The comparison group consisted of hospitalized patients with diabetes under standard care of attending physicians (mostly internal medicine-trained hospitalists). The relationship between study groups and outcome variables was assessed using Generalized Estimating Equation models.Results: 4,654 patients with diabetes (70.8 ± 0.2 years old) were admitted between January 2016 and May 2017. The IDMS team co-managed 18.3% of patients, mostly with higher severity of illness scores (p < 0.0001). Mean LOS in patients co-managed by the IDMS team decreased by 27%. Median LOS decreased over time in the IDMS group (p = 0.046), while no significant decrease was seen in the comparison group. Mean 30DR in patients co-managed by the IDMS decreased by 10.71%. Median 30DR decreased among patients co-managed by the IDMS (p = 0.048).Conclusions: In a community hospital setting, LOS and 30DR significantly decreased in patients co-managed by a specialized diabetes team. These changes may be translated into considerable cost savings.

National trends in admissions for potentially preventable conditions among patients with metastatic solid tumors, 2004-2014.

1 Background: The Centers for Medicare and Medicaid Services (CMS) has identified 10 conditions for hospitalization among patients receiving chemotherapy that are potentially preventable through appropriately managed outpatient care. CMS plans to measure hospitals’ performance based on frequency of admission for: anemia, dehydration, diarrhea, emesis, nausea, neutropenia, fever, pain, pneumonia, and sepsis. Our objective was to measure hospital utilization patterns for these conditions. Methods: Nationally representative data from the 2004 and 2014 National Inpatient Sample were analyzed. Adults with stage IV solid tumors admitted with a principal diagnosis of one of the ten conditions were identified using ICD-9 codes provided by CMS. The primary outcome was number of admissions. Secondary outcomes were total hospitalization costs, length of stay (LOS), and in-hospital mortality rate. Proportions and count data were compared using chi-square and binomial test, respectively. Results: Between 2004 and 2014, potentially preventable hospitalizations increased from 64,053 to 85,740 (p &lt; 0.01). The most frequent reason for admission was pneumonia (32%) in 2004 and sepsis (41%) in 2014. Table 1 provides the results for the year 2014 by condition. Hospitalizations for sepsis had the longest mean LOS (p &lt; 0.01), highest mean total costs (p &lt; 0.01) and most frequently resulted in death (p &lt; 0.01). Conclusions: The Department of Health and Human Services states, “Improving patients’ quality of life by keeping patients out of the hospital is a main goal of cancer care.” Despite supportive care advances, the increased frequency of hospitalization demonstrates a need for continued symptom management innovation. Infectious symptoms should be a focus of these technologies given their high prevalence, mortality and resource utilization. [Table: see text]

The Incidence of Non-Variceal Upper Gastrointestinal Hemorrhage After Percutaneous Coronary Intervention Among Patients Without Acute Myocardial Infarction Is Low: A National Analysis over 11 Months

Introduction: Dual anti—platelet therapy is standard of care after percutaneous coronary intervention (PCI). Non—variceal upper gastrointestinal hemorrhage (NVUGIH) is a potential complication in patients on dual anti—platelet therapy. Despite this known risk, there continues to be paucity of literature on the exact incidence and impact of NVUGIH after PCI. We sought to determine the incidence of NVUGIH after PCI for patients without acute myocardial infarction over an 11—month follow—up period, and its impact on mortality, morbidity and healthcare resource utilization using the largest national readmission database in the United States. Methods: This is a retrospective cohort study using the 2014 National Readmission Database. Inclusion criteria were in—hospital PCI and admissions during January. Exclusion criteria were principal diagnosis of non—ST or ST—elevation myocardial infarction and age less than 18 years. Primary outcome was incidence of NVUGIH during index admission and on 11 month follow—up. Secondary outcomes were: in—hospital and 11—month mortality, morbidity (hemorrhagic shock) and healthcare resource utilization (length of stay (LOS), mean total hospitalization costs and charges). Confounders were adjusted for using multivariate regression analysis. Results: 15,421 patients were included in the analysis. Only 0.3% and 2.7% of patients developed NVUGIH during index admission and 11 months follow, respectively. However, patients who developed NVUGIH during the index admission had higher in—hospital mortality, longer mean LOS, and higher mean total hospitalization costs and charges compared with those who did not (Table 1). Similarly, patients who experienced NVUGIH during the 11—month follow—up period had a higher 1—month mortality compared with those who did not. The NVUGIH associated additional resource utilization were also significant (Table 1). Conclusion: The incidence of non—variceal upper gastrointestinal hemorrhage after a percutaneous coronary intervention among patients without acute myocardial infarction is low both during the index admission and over an 11—month follow—up period. However, patients who develop NVUGIH after PCI have higher mortality, morbidity and healthcare resource utilization compared with those who do not.1187 Figure 1 No Caption available.

Does Multiple Sclerosis Affect the Inpatient Perioperative Outcomes After Total Hip Arthroplasty?

BackgroundThere is a paucity of studies evaluating the short-term perioperative outcomes of total hip arthroplasty (THA) in multiple sclerosis (MS) patients. Therefore, this study evaluated (1) patient factors; and (2) patient outcomes in MS THA patients compared to non-MS THA patients. MethodsThe Nationwide Inpatient Sample from 2002 to 2013 identified 5899 MS and 2,723,652 non-MS THA patients. Yearly trends, demographics, and comorbidities were compared, and then non-MS THA patients were matched (3:1) to MS THA patients by age, gender, race, comorbidity score, and surgery year. Regression analyses compared perioperative complications (any, surgical, medical), length of stay (LOS), and discharge dispositions. ResultsThe annual prevalence of MS in THA patients increased from 1.36 per 1000 THAs in 2002 to 2.54 per 1000 THAs in 2013 (P = .004). MS patients were younger, more likely female, take corticosteroids, have hip osteonecrosis, and have gait abnormalities. Compared to matched cohort, MS patients had a higher risk of any surgical (odds ratio [OR] = 1.18; 95% confidence interval [95% CI], 1.02-1.37) and any medical (OR = 1.55; 95% CI, 1.34-1.81) complications, an 8.24% longer mean LOS (95% CI, 5.61-10.94; <0.0001) and were more likely to be discharged to a care facility (OR = 2.09; 95% CI, 1.82-2.40). ConclusionOrthopedic surgeons should be cognizant of the potential increased risks after THA in MS patients. Neurologists and other practitioners may help optimize and enhance the preoperative care of potential THA candidates, and provide guidance as to the appropriate timing of intervention for hip issues in MS patients.

Early versus late inpatient awake transcervical injection laryngoplasty after thoracic aortic repair.

Vocal fold movement impairment (VFMI), a known complication following thoracic aortic surgery, has been associated with poorer surgical outcomes, including higher pulmonary complications and longer length of stay (LOS). Awake transcervical injection laryngoplasty in the inpatient setting serves to augment pulmonary toilet function for affected patients. This study investigates clinical outcomes of patients who underwent early versus late injection laryngoplasty following aortic surgery. A 5-year review (2011-2016) of 35 patients who underwent inpatient injection laryngoplasty for VFMI following aortic repair was conducted. Data included demographics, surgery parameters, laryngologic evaluation, pulmonary complications, LOS, and mortality. Early injection was defined as within 5 days from extubation. Statistical analyses were performed using SPSS, version 17.0 (IBM Corp., Armonk, NY). All 35 patients (mean age 56, 77% male) underwent left vocal-fold injection laryngoplasty without complication. There were 15 (43%) early procedures and 20 (57%) late procedures. Mean LOS for early and late injection groups (13 vs. 20 days, respectively) significantly differed (P = 0.04, 95% confidence interval (CI) 0.3 to 14.4). Early laryngoplasty cohorts experienced less pulmonary complications (20%) than those who had late medialization (50%), but this did not reach significance (P = 0.06, 95% CI -0.3 to 8.1). The most common complication type in both groups was therapeutic bronchoscopy. Early awake injection laryngoplasty within 5 days from extubation is feasible and may improve clinical outcomes for patients with VFMI following aortic repair. Further prospective studies on this approach for VFMI after thoracic surgery are needed. 4. Laryngoscope, 128:144-147, 2018.

Comorbidities Have a Greater Impact Than Age Alone in the Outcomes of Octogenarian Total Knee Arthroplasty

BackgroundIncreasing age and various comorbidities are known risk factors for complications after total knee arthroplasty (TKA), but data on the impact of total comorbidity burden is scarce. We investigated the effect of age and total comorbidity burden on outcomes after primary TKA in octogenarians (OGs). MethodsA matched-pair comparison study was conducted using prospectively collected TKA registry data in a large tertiary institution. Between 2006 and 2011, consecutive OGs undergoing primary unilateral TKA, with minimum 2-year follow-up, were matched 1:1 with younger controls based on demographic and surgical variables. We compared the Charlson comorbidity index (CCI), complication rate, length of stay (LOS), 30-day readmission, and 2-year reoperation rate. Multivariate analysis was performed to determine the effects of age and CCI on each outcome. ResultsThere were 209 OGs and 209 controls. OGs were significantly older (mean age 82.1 vs 66.1 years, P < .001) and had higher CCI. OGs had longer mean LOS (6.3 vs 5.4 days, P = .001), and a trend for more complications and readmissions. The complication rate increased from 7.5% for CCI = 0, to 33.3% for CCI ≥3 (P = .005). The LOS increased from 5.4 days for CCI = 0, to 9.6 days for CCI ≥3 (P < .001). Multivariate analysis showed that higher CCI was an independent risk factor for complications and longer LOS, whereas age was not. ConclusionComorbidity burden has a greater impact than age alone on TKA outcomes in OGs. Well-selected OGs remain good candidates for TKA.

The SOAR stroke score predicts hospital length of stay in acute stroke: an external validation study.

The objective of this study is to externally validate the SOAR stroke score (Stroke subtype, Oxfordshire Community Stroke Project Classification, Age and prestroke modified Rankin score) in predicting hospital length of stay (LOS) following an admission for acute stroke. We conducted a multi-centre observational study in eight National Health Service hospital trusts in the Anglia Stroke & Heart Clinical Network between September 2008 and April 2011. The usefulness of the SOAR stroke score in predicting hospital LOS in the acute settings was examined for all stroke and then stratified by discharge status (discharged alive or died during the admission). A total of 3596 patients (mean age 77 years) with first-ever or recurrent stroke (92% ischaemic) were included. Increasing LOS was observed with increasing SOAR stroke score (p < 0.001 for both mean and median) and the SOAR stroke score of 0 had the shortest mean LOS (12 ± 20 days) while the SOAR stroke score of 6 had the longest mean LOS (26 ± 28 days). Among patients who were discharged alive, increasing SOAR stroke score had a significantly higher mean and median LOS (p < 0.001 for both mean and median) and the LOS peaked among patients with score value of 6 [mean (SD) 35 ± 31 days, median (IQR) 23 (14-48) days]. For patients who died as in-patient, there was no significant difference in mean or median LOS with increasing SOAR stroke score (p = 0.68 and p = 0.79, respectively). This external validation study confirms the usefulness of the SOAR stroke score in predicting LOS in patients with acute stroke especially in those who are likely to survive to discharge. This provides a simple prognostic score useful for clinicians, patients and service providers.

Impact of Comorbidities on Length of Stay and Mortality in Hospitalized Patients with Cancer and Febrile Neutropenia

Background: Hematologic toxicities are common side effects of cancer chemotherapy. Despite advances in supportive care, febrile neutropenia (FN) continues to represent a serious adverse event often requiring hospitalization and is associated with an increased risk of mortality. The purpose of this analysis was to investigate the impact of comorbidities and infectious complications on in-patient length of stay (LOS) and mortality in hospitalized patients with cancer and neutropenia over the past decade. Methods: Hospitalization data from the University Health Consortium database inclusive of the years 2004-2012 from 239 US medical centers were analyzed. Cancer type, presence of neutropenia, comorbidities, and infection type were based on ICD-9-CM codes recorded during hospitalization. This analysis includes adult patients with malignant disease and neutropenia. Patients undergoing bone marrow or stem cell transplantation were excluded. For patients with multiple hospitalizations, the first admission during the time period studied was utilized. Primary study outcomes included hospital length of stay (LOS≥10 days) and in-hospital mortality. Multivariate logistic regression analysis was utilized to study the impact of major comorbidities on the primary outcomes. Major comorbidities under consideration included heart, liver, lung, renal, cerebrovascular, peripheral-vascular disease, diabetes and venous thromboembolism. Results: Among 135,309 patients with cancer hospitalized with neutropenic events, one-third were age 65 years or older and 51% were male. Approximately one-quarter (24.5%) of patients experienced more than one admission with FN. The mean (median) length of stay increased progressively from 11.1 (6) days in 2004 to 12.8 (7) days in 2012. Patients with leukemia, lymphoma and central nervous system (CNS) malignancies experienced the longest mean LOS (21.4, 10.5, 10.2 days, respectively). Overall, 50,846 (37.6%) had a LOS≥10 days and 10,261 (7.6%) patients died during the hospitalization with no difference seen over the time period of observation. (P=.30). Greater rates of mortality were observed in patients with lung (11.2%) or CNS (9.3%) malignancies, and leukemia (9.3%). Infectious complications were documented in 59.5% of patients and their presence was associated with greater LOS≥10 days (48.2% vs. 22.0%) and higher mortality (11.2% vs. 2.3%). Greater LOS≥10 days (51.6% vs. 37.1%) and increased mortality (9.8% vs. 7.5%) were also observed among obese patients with cancer. Likewise, patients with multiple comorbid conditions had more prolonged hospitalizations and a greater risk of in-hospital mortality. (Table) Abstract 2601. Table Solid tumors Lymphoma LeukemiaNo. of comorbiditiesNo. of patients% died% with LOS≥10 daysNo. of patients% died% with LOS≥10 daysNo. of patients% died% with LOS≥10 days017,8580.911.28,1890.617.010,3950.853.5118,1723.417.97,7512.626.611,3803.463.2214,2508.927.25,3868.141.08,6039.769.937,49918.038.42,86118.455.25,04022.877.742,70525.151.41,06033.670.52,00438.183.1≥ 560235.262.327839.980.657749.087.0All patients*61,0867.022.625,5256.632.237,9999.265.4 LOS – length of stay; * 10,699 patients with other type or multiple tumors not included in the table The trend toward longer LOS and greater mortality with increased number of comorbidities persisted in multivariate analyses after adjusting for cancer type, age, gender, ethnicity and type of infection (odds ratio (OR) per +1 comorbidity increase: [mortality: OR =1.89; 95% CI: 1.85-1.92; P&lt;.0001], [LOS: OR=1.56; 95% CI: 1.54-1.58; P&lt;.0001]). Conclusions: Major medical comorbidities are common among hospitalized patients with cancer and neutropenia. Importantly, such comorbidities are associated with prolonged hospitalization and increased risk of in-hospital mortality with significantly worse outcomes in patients with lymphoma or leukemia. Greater awareness of risk factors associated with poor prognosis in cancer patients hospitalized with neutropenic complications as well as validated risk tools to better identify low risk as well high risk patients may guide more personalized cancer care, potentially improving clinical outcomes and lowering the cost of care. Disclosures Crawford: Amgen: Consultancy. Dale:Amgen: Consultancy, Honoraria, Research Funding. Lyman:Amgen: Research Funding.

Factors Influencing the Length of Hospital Stay in Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease Admitted to Intensive Care Units

The cost of hospital admissions for acute exacerbations of COPD (AECOPD) accounts for 70% of total costs for the treatment of COPD patients. We wanted to identify clinical parameters associated with a longer length of stay (LOS) in these patients. We reviewed electronic medical records of patients with AECOPD admitted between January 1, 2006, and December 31, 2010. The inclusion criteria were age 45 years or older, the diagnosis of AECOPD by GOLD (Global Initiative for Chronic Obstructive Lung Disease) guideline criteria, and admission to an intensive care unit. We compared the quartile with the longest LOS group with the other 3 quartiles using routine clinical data. 217 patients met inclusion criteria. The mean age was 67.4 ± 10.9 years, 47% were male, the mean FEV1s (forced expiratory volume in 1 second) was 42.4% ± 17.4% of predicted, and the mean LOS was 9.0 ± 6.0 days. Univariate analysis demonstrated that nursing home status, low albumins, the presence of pleural effusions, intubation, and high APACHE II scores were associated with increased LOS (P < .05 for each factor). Multivariate logistic regression demonstrated that the need for intubation (P < .001) predicted an increased LOS. Our study demonstrates that intubation for mechanical ventilation increased the LOS in patients with AECOPD. More intensive interventions in these patients might decrease the LOS and improve outcomes.

Emergency department crowding in The Netherlands: managers’ experiences

BackgroundIn The Netherlands, the state of emergency department (ED) crowding is unknown. Anecdotal evidence suggests that current ED patients experience a longer length of stay (LOS) compared to some years ago, which is indicative of ED crowding. However, no multicenter studies have been performed to quantify LOS and assess crowding at Dutch EDs. We performed this study to describe the current state of emergency departments in The Netherlands regarding patients’ length of stay and ED nurse managers’ experiences of crowding.MethodsA survey was sent to all 94 ED nurse managers in The Netherlands with questions regarding the type of facility, annual ED census, and patients’ LOS. Additional questions included whether crowding was ever a problem at the particular ED, how often it occurred, which time periods had the worst episodes of crowding, and what measures the particular ED had undertaken to improve patient flow.ResultsSurveys were collected from 63 EDs (67%). Mean annual ED visits were 24,936 (SD ± 9,840); mean LOS for discharged patients was 119 (SD ± 40) min and mean LOS for admitted patients 146 (SD ± 49) min. Consultation delays, laboratory and radiology delays, and hospital bed shortages for patients needing admission were the most cited reasons for crowding. Admitted patients had a longer LOS because of delays in obtaining inpatient beds. Thirty-nine of 57 respondents (68%) reported that crowding occurred several times a week or even daily, mostly between 12:00 and 20:00. Measures taken by hospitals to manage crowding included placing patients in hallways and using fasttrack with treatment of patients by trained nurse practitioners.ConclusionsDespite a relatively short LOS, frequent crowding appears to be a nationwide problem according to Dutch ED nurse managers, with 68% of them reporting that crowding occurred several times a week or even daily. Consultations delays, laboratory and radiology delays, and hospital bed shortage for patients needing admission were believed to be the most important factors contributing to ED crowding.