Nationwide Cohort Analysis Research Articles

Complications and Reoperations after Carpal Tunnel Decompression: A Nationwide Cohort Analysis of Risk Factors in 855 838 Surgeries in the NHS in England

Background: Healthcare related costs for carpal tunnel decompression surgery (CTD) to treat carpal tunnel syndrome (CTS) exceed two billion dollars per year, despite a scarcity of data on safety and effectiveness. We estimated the incidence of revision surgery and complications following CTD, and the patient factors associated with adverse outcomes. Methods: We included all CTD surgeries undertaken in England using the Hospital Episode Statistics dataset linked to mortality records from 01/04/1998 until 31/03/2017. Patients were followed up until death or 31/03/2017. Primary outcomes were the overall incidence of revision CTD and postoperative complications (surgical site infection or dehiscence requiring surgery, neurovascular or tendon injury) within 30 and 90 days of surgery. Multivariable Cox regression analysis was used to identify factors influencing complications and revision surgery. The Fine and Gray method was used to adjust for the competing risk of mortality. Findings: 855 838 CTDs were performed during the 19-year period (incidence rate 1.10 per 1000 person years [95% CI 1·02 to 1·17]). Complication rates were 0·07% (95% CI 0·067 to 0·078) within 30 days, 0·08% (95% CI 0·073 to 0·085) within 90 days. 90-day local complications were associated with male sex and age category 18-29 years (adjusted hazard ratios 2·32 [1·74 to 3·09], 2·25 [1·10 to 4·62] respectively). 3·4% underwent revision CTD (incidence rate 3·18 per 1000 person years [95% CI 3·12 to 3·23]). Male sex, increasing age, greater levels of comorbidity, and increasing socioeconomic deprivation were associated with increased revision risk (adjusted subhazard ratios 1·09 [95% CI 1·05 to 1·13]; 1·09 [1·03 to 1·15]; 1·25 [1·19 to 1·32] and 1·18 [1·10 to 1·27]). Interpretation: This is the largest national study on CTD to date, providing the best available evidence on complication and revision rates. CTD is a safe operation, with an overall complication rate of less than 0.1%. Funding: Versus Arthritis; Medical Research Council; RCS England/ NJR research fellowship; University of Oxford; National Institute for Health Research; NIHR Biomedical Research Centre, Oxford. Declaration of Interest: All authors have completed the ICMJE uniform disclosure and declare: no support from any organization for the submitted work; D P-A has received research grants from Amgen, Servier, UCB; departmental fees for speaker services from Amgen, departmental fees for consultancy from UCB. No other relationships or activities could appear to have influenced the submitted work. Ethical Approval: This study was approved by the University of Oxford Research Services Clinical Trials Research Group (project ID 12787), and the NHS Data Access Advisory Group (DAAG). It was carried out in accordance with the NHS Digital Data Sharing Agreement (DARS-NIC-29827-Q8Z7Q) and registered at clinicaltrials.gov (NCT03573765). Studies using non-identifiable records from Hospital Episode Statistics are exempt from research ethics committee approval.

Readmission after neurosurgical intervention in epilepsy: A nationwide cohort analysis.

Hospital readmissions result in increased health care costs and are associated with worse outcomes after neurosurgical intervention. Understanding factors associated with readmissions will inform future studies aimed at improving quality of care in those with epilepsy. Patients of all ages with epilepsy who underwent a neurosurgical intervention were identified in the 2014 Nationwide Readmissions Database, a nationally representative dataset containing data from roughly 17 million US hospital discharges. Diagnosis of epilepsy was based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-based case definitions. Neurosurgical interventions for epilepsy: resective/disconnective surgery, responsive neurostimulation/deep brain stimulation, vagus nerve stimulation, radiosurgery, and intracranial electroencephalography were identified using ICD-9-CM procedure codes. Primary outcome was all-cause 30-day readmission following discharge from the index hospitalization. There were a total of 2284 index surgical admissions. Overall, 10.83% (n=251) of patients following an index epilepsy surgery admission were readmitted within 30days. Factors independently associated with 30-day readmission for all epilepsy surgery admissions were: Medicare insurance (P<.01), discharge disposition that was not home (P<.01), higher Elixhauser comorbidity indexes (P<.01), longer length of stay (P<.01), and adverse events of surgical and medical care during index stay (P=.04). In the multivariate model, Medicare insurance (hazard ratio [HR] 1.81 [1.29-2.53], P<.01) and length of stay (HR 1.02 [1.01-1.04], P<.01) remained significant independent predictors for 30-day readmission. The most common primary reason for readmissions was epilepsy/convulsions accounting for 22.85%. Our results suggest that careful management of postoperative seizures and discharge planning after epilepsy surgery may be important to optimize outcomes and reduce the risk of readmission, particularly for patients on Medicare.

Risk of Polycystic Ovary Syndrome in Women Exposed to Fine Air Pollutants and Acidic Gases: A Nationwide Cohort Analysis.

Background: Air pollutants cause endocrine disorders and hormone disruption. The relationship between air pollutants and polycystic ovary syndrome (PCOS) must be carefully investigated using a nationwide cohort. Methods: Data were extracted from two nationwide databases, namely Longitudinal Health Insurance Database and Taiwan Air Quality Monitoring Database, and analyzed. The study considered a range of data that began on 1 January 2000 and ended on 31 December 2013. Women diagnosed with PCOS were excluded. From the residential data, the study assessed the daily concentrations of sulfur dioxide (SO2), nitrogen oxides (NOx), nitrogen monoxide (NO), nitrogen dioxide (NO2), and PM2.5 the women were exposed to. A Cox proportional hazard regression model was applied to assess PCOS risk. Results: In total, 91,803 women were enrolled in this study; of those women, 2072 developed PCOS after 12 years of follow-up. The mean daily concentrations of SO2, NOx, NO, NO2, and PM2.5 women were exposed to were 4.25 (±1.44) ppb, 20.41 (±6.65) ppb, 9.25 (±4.36) ppb, 20.99 (±3.33) ppb, and 30.85 (±6.16) μg/m3, respectively. Compared with the first-quartile levels of exposure, the fourth-quartile levels of exposure to SO2, NOx, NO, NO2, and PM2.5 increased PCOS risk by 10.31 times (95% CI = 8.35–12.7), 3.37 times (95% CI = 2.86–3.96), 4.18 times (95% CI = 3.57–4.89), 7.46 times (95% CI = 6.38–8.71), and 3.56 times (95% CI = 3.05–4.15), respectively. Conclusion: Women exposed to a high concentrations of air pollutants, namely SO2, NO, NO2, NOx, and PM2.5, had a high PCOS risk.

Risk of Dementia in Patients with Leptospirosis: A Nationwide Cohort Analysis

Background: Studies have linked some bacterial infections with an increased likelihood for development of dementia. However, there is a paucity of data on the relationship between dementia and leptospirosis. In view of this, we conducted a retrospective cohort study to determine whether leptospirosis is a risk factor for dementia. Methods: Data were collected from the Taiwan National Health Insurance Research Databases (2000–2010) to investigate the incidence of and risk factors for dementia in patients with leptospirosis. Patients with leptospirosis who did not have a history of dementia were enrolled in the study. For each leptospirosis patient, four controls were randomly selected after frequency matching of age, sex, and index date. Cox proportional hazard regression models were used for the analyses of dementia risk. Results: A greater risk of dementia was observed in the leptospirosis cohort than in the non-leptospirosis cohort both in patients without any comorbidity (adjusted HR (aHR) = 1.23, 95% CI = 1.06–1.43) and with a comorbidity (aHR = 2.06, 95% CI = 1.7–2.5). Compared with the non-leptospirosis cohort without these comorbidities, the leptospirosis cohort with ≥2 comorbidities exhibited a significantly increased risk of dementia (aHR = 6.11, 95% CI = 3.15–11.9), followed by those with any one comorbidity (adjusted HR = 3.62, 95% CI = 1.76–7.46). Conclusions: Patients with leptospirosis were at a 1.89-fold greater risk of subsequent dementia, but potential genetic susceptibility bias in the study group is a major confound.

Is There a Safety Signal for Dolutegravir and Integrase Inhibitors During Pregnancy?

Dolutegravir, an integrase strand transfer inhibitor (InSTI), is a major antiretroviral agent for HIV infection. Its use is promising, especially in low- and middle-income countries, because of a high resistance barrier and a good safety profile. Very recently, a World Health Organization safety signal has been raised regarding neural tube defects after the first-trimester exposure. Furthermore, to date, the experience is limited regarding the use of the other InSTI drugs (raltegravir and elvitegravir) during pregnancy. Our objective is to analyze the safety of InSTI drugs in pregnant women. Nation-wide database cohort analysis. We evaluated the risk of major birth defects according to EUROCAT classification in pregnant women, which had had a first-trimester exposure to dolutegravir, raltegravir, or elvitegravir. We found a major birth defect rate of 1.9% in the general population between 2012 and 2016. As InSTI drugs are not used as first-line therapy in pregnant women, we found a very low exposure in this population. Among 49, 240, and 70 pregnancy outcomes exposed to dolutegravir, raltegravir, and elvitegravir, respectively, during the first trimester, there were 2, 3, and 1 major birth defects, respectively. There was no case of neural tube defect. Drug exposure to InSTI is limited in our nation-wide database. Nevertheless, our data do not support a pharmacovigilance signal on neural tube defects in women exposed to dolutegravir, raltegravir or elvitegravir during pregnancy. Owing to a small number of pregnancy outcomes, these results need to be confirmed with further studies.

Vaccine-Preventable Diseases in Hospitalized Patients With Inflammatory Bowel Disease: A Nationwide Cohort Analysis

Inflammatory bowel disease (IBD) entails a higher risk of infections, including those that could be prevented with immunizations. Current Advisory Committee on Immunization Practices and American College of Gastroenterology vaccine recommendations for patients with IBD are based on low levels of evidence. We conducted a population-based descriptive cohort study using the US National Inpatient Sample ICD-9 codes from 2012 to 2015. We measured the frequency of patients with IBD who were admitted to the hospital with a vaccine-preventable disease (VPD). Frequencies and demographics were determined and compared between patients with IBD and patients without IBD. Of discharges, 596,485 (2.08%) were secondary to a VPD, and 7180 (1.2%) were found to have both a VPD and IBD (including Crohn disease and ulcerative colitis). The most common VPDs among patients with IBD were herpes zoster virus (HZV) (34.9%) and hepatitis B virus (31.6%), followed by influenza (22.1%). Pneumococcal pneumonia (9.1%) and hepatitis A virus (2.4%) were less common. Inpatients with IBD were twice as likely to have HZV when compared to non-IBD inpatients (odds ratios [OR] = 2.30 [95% CI, 2.06-2.58], P < 0.0001) This finding was consistent for every study year. Pneumococcal pneumonia [OR = 0.62 (95% CI, 0.52-0.74), P < 0.0001] and influenza [OR = 0.72 (95% CI, 0.63-0.81), P < 0.0001] were significantly lower in the IBD population. There was no difference for other VPDs. HZV was the most frequent VPD in IBD inpatients. Patients with IBD have a higher rate of hospital admissions with HZV and a lower rate of pneumococcal pneumonia and influenza admissions when compared with non-IBD patients. For other VPDs, patients with IBD have the same rate of admission as the general population.

Lead Time Bias May Contribute to the Shorter Life Expectancy in Post-colonoscopy Colorectal Cancer.

The long-term outcomes of post-colonoscopy colorectal cancer have varied in previous studies. Our nationwide cohort analysis estimated expected years of life lost to adjust for lead time bias. We recalculated the long-term outcomes for post-colonoscopy and detected colorectal cancer. Patients with colorectal cancer registered in the Taiwan Cancer Registry between 2002 and 2009 were enrolled. The detected group included 22,169 cases of colorectal cancer confirmed within 6months after a colonoscopy. The post-colonoscopy group included 1653 cancer patients who received a colonoscopy 6-60months before diagnosis. Patients were followed up until 2011. We simulated age-, sex-, and calendar year-matched referents from life tables in the Taiwan National Vital Statistics using a Monte Carlo method. The life expectancy and expected years of life lost of the cancer patients were obtained from extrapolation of the logit transformation of the survival ratio between the cancer cohorts and the referent groups. Post-colonoscopy colorectal cancer had shorter life expectancies than detected cancer (stages 2-4: 13.6 vs. 16.1years; 8.7 vs. 12.6years; 2.1 vs. 4.1years, p < 0.001). The loss-of-life expectancy did not show this trend after adjusting for lead time bias. Post-colonoscopy colorectal cancer was found at an older age, more often proximal, and was associated with previous endoscopic polypectomy procedures (p < 0.001). Post-colonoscopy colorectal cancer leads to a shorter life expectancy, which appears partially explained by the presence of lead time bias. Quality assurance for colonoscopy and close surveillance for high risk groups would reduce post-colonoscopy colorectal cancer.

Role of local treatment including radiotherapy in Barcelona Clinic of Liver Cancer stage C patients: a nationwide cohort analysis in South Korea.

PurposeSorafenib is recommended as the standard treatment for hepatocellular carcinoma (HCC) of Barcelona Clinic of Liver Cancer stage C (BCLC C). However, local treatment including radiation therapy (LRT) is also widely administered in practice. The aim of our study was to define the role of LRT among BCLC C patients.Patients and methodsOf the patients with HCC enrolled the Korean Central Cancer Registry from 2008 to 2014, the Korean Liver Cancer Study Group randomly extracted 10,580 patient data from ~50 hospitals nationwide. Among them, 3,401 patients were categorized to have BCLC C HCC. Among them, patients with information on initial treatments, defined as the first and secondary treatment within 60 days after the first treatment, were selected and classified into three initial treatment groups: LRT, sorafenib, and no treatment.ResultsAmong 3,401 BCLC C HCC patients, 1,486 were included in the study and the remaining patients were excluded as they did not meet the criteria (eg, underwent local treatments without radiotherapy [RT] or received chemotherapy other than sorafenib). Of these, 266 were assigned to LRT (17.9%), 316 to sorafenib (21.3%), and 904 to no treatment group (60.8%). Median survival time of the sorafenib group was shorter than that of the LRT group (3.8 vs 7.6 months, P<0.001). In multivariable analysis, sorafenib group showed significantly higher risk related to mortality compared to LRT group, not only among all patients (HR: 1.50, 95% CI: 1.23–1.84) but also between subgroup cohorts with portal invasions (1.55, 1.23–1.84), with lymph node metastases (2.42, 1.53–3.83), without distant metastases (1.43, 1.10–1.87), and with distant metastases (1.57, 1.13–2.19). Additionally, no treatment group showed the worst survival among the three treatment groups not only in all patients, but also in all subgroups of patients (P<0.001 in all).ConclusionLRT as an initial treatment showed survival benefit as compared to sorafenib in HCC patients of BCLC C.

Scrub typhus and depression: a nationwide cohort analysis

BackgroundStudies on the relationship between depression and scrub typhus are limited. We conducted a retrospective cohort study to investigate whether scrub typhus is a risk factor for depression.MethodsUsing Taiwan’s National Health Insurance Research Database, this study investigated the incidence of depression, and its risk factors, in patients diagnosed with scrub typhus between 2000 and 2010. Scrub typhus patients who did not have a history of depression before the index date were enrolled. For each patient with scrub typhus, four controls without a history of scrub typhus and depression were randomly selected and frequency matched by sex, age, year of the index date, and comorbidities. The follow-up period was from the time of initial scrub typhus diagnosis to the date of diagnosis of depression, censoring, or December 31, 2010. Cox proportional hazards regression models were used to analyze the risk of depression according to sex, age, and comorbidities.ResultsThe study comprised a 5238-patient scrub typhus group and a 20,952-patient non-scrub typhus group with similar sex and age distributions. During the follow-up period, the cumulative incidence of depression was higher in the scrub typhus than the non-scrub typhus group (log-rank test P < 0.001). In the scrub typhus group, 45 patients developed depression, yielding an incidence rate of 1.67 per 1000 person-years, and in the non-scrub typhus group, 117 patients developed depression, yielding an incidence rate of 1.08 per 1000 person-years. This yielded a crude hazard ratio (HR) of 1.55 (95% confidence interval [CI] 1.41–1.70) and adjusted HR (aHR) of 1.56 (95% CI 1.42–1.71). Compared with the non-scrub typhus group, the risk of depression in the scrub typhus group was higher in patients of both sexes (men: aHR = 1.46, 95% CI 1.29–1.64; women: aHR = 1.68, 95% CI 1.45–1.96), in patients aged younger than 65 (≤ 49 years: aHR = 1.95, 50–64 years: aHR = 1.73), and in patients without comorbidities (aHR = 2.06, 95% CI 1.85–2.29).ConclusionsThe risk of depression was 1.56-fold higher in patients with scrub typhus than in the general population.

Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in US Hospitals: 2010-2014.

Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and -9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.

13 - Vaccine-Preventable Diseases in Hospitalized Patients with Inflammatory Bowel Disease: A Nationwide Cohort Analysis

13 - Vaccine-Preventable Diseases in Hospitalized Patients with Inflammatory Bowel Disease: A Nationwide Cohort Analysis

Preeclampsia and scleroderma: a prospective nationwide analysis.

In a preliminary case-control study, women with scleroderma more frequently reported having had hypertensive complications during pregnancy compared with healthy women. To prospectively investigate this possible association, we conducted a nation-wide cohort analysis of a major hypertensive complication during pregnancy, namely preeclampsia, and later scleroderma. Analyses were based on Danish register-based birth and hospital contact data on preeclampsia and scleroderma. We followed 778,758 women from time of giving birth between 1978 and 2010 to end of follow-up, emigration, death, or scleroderma diagnosis, whichever occurred first. The association was evaluated by incidence rate ratios, obtained in Poisson regression models. We report that preeclampsia is associated with a 69% significantly increased risk of later developing scleroderma. Though these findings do not impact clinical care directly, the association of preeclampsia with scleroderma underscores the significant relation of preeclampsia and other adverse pregnancy outcomes with later disease in women and should be included in patient counseling and education.

National Temporal Trends of Intensive Medical Procedures and Palliative Care During Terminal Hospitalization Among Patients With Esophageal Cancer in the U.S.

Introduction: Life expectancy of patients with esophageal cancer is still limited. This has been cited as evidence that people dying in the U.S. hospitals are receiving more intensive medical intensive procedures and palliative care. This study is to examine the temporal trends in the use of intensive medical procedures and palliative care during the terminal hospitalization of patients with esophageal cancer.Table: Table. Temporal trends of procedures, procedure-free status, and palliative care in patients with esophageal cancerFigureMethods: A retrospective nationwide cohort analysis was performed, using the National Inpatient Sample (NIS) between years 2010 and 2014. All patients ≥ 18 years of age and descendants with a principal diagnosis of esophageal cancer were included. Survey weights were applied from the NIS to provide national population estimates. Systemic support procedures were defined as life-sustaining treatments: (1) intubation, (2) invasive ventilation, (3) non-invasive mechanical ventilation, (4) enteral infusion, (5) parenteral infusion, (6) cardiopulmonary resuscitation, (7) blood transfusion, (8) hemodialysis; local procedures analyzed included (1) endoscopy, (2) percutaneous gastro (jejunostomy), (3) esophageal dilatation using the International Classification of Diseases, 9th revision, Clinical Modification. Palliative care consultation and Do-Not-Resuscitate (DNR) data were also compared. We analyzed temporal trends by using Rao-Scott chi-square analysis between each procedure (or palliative care) and each year. Results: A total of 37,312,324 hospitalizations were examined. There were 5,113 weighted patients with esophageal cancer. The temporal trends of both systemic support procedure and local procedure utilization were unchanged over time. There was increasing palliative care consultation and DNR status in patients with esophageal cancer (p = .007 and p < .0001, respectively). Conclusion: Among adults who died from esophageal cancer in the U.S. hospitals from year 2010 to 2014, temporal trends showed unchanging systemic support procedures and local procedures. However, palliative care utilization was rising. We speculate that limited life expectacy of esophageal cancer patients might negate temporal trends of increasing intensive medical procedures at the end of life.

Leptospirosis and Depression: A Nationwide Cohort Analysis.

We conducted a retrospective cohort study to investigate whether leptospirosis is a risk factor for depression. From the Taiwan National Health Insurance Research Database between 2000 and 2010, patients with leptospirosis (ICD-9 code 100) who did not have a history of depression (ICD-9-CM codes 296.2, 296.3, 300.4, and 311) before the index date were enrolled (leptospirosis cohort). For each patient with leptospirosis, 1 control without a history of leptospirosis and depression was randomly selected (nonleptospirosis cohort). Cox proportional hazards regression models were used to analyze the risk of depression according to sex, age, and comorbidities. In the leptospirosis and nonleptospirosis cohorts, we observed 34 patients with depression, with the incidence rate of 2.87 per 1,000 person-years, and 25 patients with depression, with the incidence rate of 1.93 per 1,000 person-years, respectively, yielding a crude hazard ratio (HR) of 1.49 (95% confidence interval [CI], 1.25-1.77) and an adjusted HR (aHR) of 1.58 (95% CI, 1.34-1.88). Compared with the nonleptospirosis cohort, the leptospirosis cohort had a risk of depression stratified by sex, age, and comorbidity that was higher in female patients (aHR = 2.08; 95% CI, 1.54-2.80), patients younger than 49 years old (aHR = 3.19; 95% CI, 2.39-4.27), and patients without comorbidity (aHR = 2.14; 95% CI, 1.68-2.71). The risk of depression was higher in women than in men (aHR = 1.90; 95% CI, 1.61-2.25) and in patients with comorbidities, namely hyperlipidemia (aHR = 1.80; 95% CI, 1.40-2.31), coronary artery disease (aHR = 2.47; 95% CI, 1.96-3.12), stroke (aHR = 1.77; 95% CI, 1.39-2.24), and septicemia (aHR = 2.06; 95% CI, 1.64-2.58). Patients with leptospirosis have a 1.58-fold higher risk of depression than that in the general population. Physicians should be alert to the emotional condition and depression symptoms of people who had been suffering from leptospirosis.

Association of Household Income Level and In-Hospital Mortality in Patients With Sepsis: A Nationwide Retrospective Cohort Analysis.

Associations between low socioeconomic status (SES) and poor health outcomes have been demonstrated in a variety of conditions. However, the relationship in patients with sepsis is not well described. We investigated the association of lower household income with in-hospital mortality in patients with sepsis across the United States. Retrospective nationwide cohort analysis utilizing the Nationwide Inpatient Sample (NIS) from 2011. Patients aged 18 years or older with sepsis were included. Socioeconomic status was approximated by the median household income of the zip code in which the patient resided. Multivariate logistic modeling incorporating a validated illness severity score for sepsis in administrative data was performed. A total of 8 023 590 admissions from the 2011 NIS were examined. A total of 671 858 patients with sepsis were included in the analysis. The lowest income residents compared to the highest were younger (66.9 years, standard deviation [SD] = 16.5 vs 71.4 years, SD = 16.1, P < .01), more likely to be female (53.5% vs 51.9%, P < .01), less likely to be white (54.6% vs 76.6%, P < .01), as well as less likely to have health insurance coverage (92.8% vs 95.9%, P < .01). After controlling for severity of sepsis, residing in the lowest income quartile compared to the highest quartile was associated with a higher risk of mortality (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 1.03-1.08, P < .01). There was no association seen between the second (OR: 1.02, 95% CI: 0.99-1.05, P = .14) and third (OR: 0.99, 95% CI: 0.97-1.01, P = .40) quartiles compared to the highest. After adjustment for severity of illness, patients with sepsis who live in the lowest median income quartile had a higher risk of mortality compared to residents of the highest income quartile. The association between SES and mortality in sepsis warrants further investigation with more comprehensive measures of SES.

Editor's Choice – Dual Antiplatelet Therapy Improves Outcome in Diabetic Patients Undergoing Endovascular Femoropopliteal Stenting for Critical Limb Ischaemia

The purpose of this study was to analyse the effect of dual antiplatelet therapy (DAPT) compared to aspirin on outcome after endovascular interventions in patients with CLI. This was a population based retrospective nationwide cohort analysis. Several linked national databases in Sweden: Swedish National Vascular Registry, Prescribed Drug Registry and National Discharge Registry. A total of 1941 patients (median age 79; range 43-103 years; women 58%) were identified with CLI who had undergone primary femoropopliteal endovascular intervention between 2006 and 2012. Of these, 599 (31%) patients were treated after the intervention with DAPT (aspirin and clopidogrel) and 1342 (69%) patients were treated with aspirin only. Percutaneous transluminal angioplasty (PTA) was performed in 1131 patients (58%), stenting in 633 patients (33%), and subintimal angioplasty (SAP) in 177 patients (9%). DAPT was given after PTA, stenting, and SAP to 17% (n=188), 53% (n=334), and 44% (n=77) of the patients, respectively. During the study period, 77 patients (13%) with DAPT and 228 patients (17%) with aspirin underwent a major amputation. Patients receiving DAPT after stenting had a lower rate of amputation (HR 0.56; 95% CI 0.36-0.86) than patients receiving aspirin alone. In the subgroup analysis, the protective effect of DAPT on amputation seemed to be confined to patients with diabetes mellitus receiving a stent (HR 0.26; 95% CI 0.13-0.52; p<.001). DAPT after PTA or SAP did not influence limb salvage, and there was no overall difference in mortality. There was no significant difference in bleeding complications between DAPT and aspirin. DAPT with aspirin and clopidogrel compared to aspirin alone was associated with a lower amputation rate but not a higher bleeding rate in patients with diabetes and CLI after endovascular femoropopliteal stenting.

FRI-013 - Palliative care access for hospitalized patients with end stage liver disease across the United States

Patients with end-stage liver disease (ESLD) often have a high symptom burden. Historically, palliative care (PC) services have been underused in this population. We investigated the use of PC services in patients with ESLD hospitalized across the United States. We used the Nationwide Inpatient Sample to conduct a retrospective nationwide cohort analysis. All patients >18 years of age admitted with ESLD, defined as those with at least two liver decompensation events, were included in the analysis. A multivariate logistic regression model predicting referral to PC was created. We analyzed 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Sample, with 39,349 (0.07%) patients meeting study inclusion. PC consultation was performed in 1,789 (4.5%) ESLD patients. The rate of PC referral in ESLD increased from 0.97% in 2006 to 7.1% in 2012 (P < 0.01). In multivariate analysis, factors associated with lower referral to PC were Hispanic race (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.66-0.89; P < 0.01) and insurance coverage (OR, 0.74; 95% CI, 0.65-0.84; P < 0.01). Factors associated with increased referral to PC were age (per 5-year increase, OR, 1.05; 95% CI, 1.03-1.08; P < 0.01), do-not-resuscitate status (OR, 16.24; 95% CI, 14.20-18.56; P < 0.01), treatment in a teaching hospital (OR, 1.25; 95% CI, 1.12-1.39; P < 0.01), presence of hepatocellular carcinoma (OR, 2.00; 95% CI, 1.71-2.33; P < 0.01), and presence of metastatic cancer (OR, 2.39; 95% CI, 1.80-3.18; P < 0.01). PC referral was most common in west coast hospitals (OR, 1.81; 95% CI, 1.53-2.14; P < 0.01) as well as large-sized hospitals (OR, 1.49; 95% CI, 1.22-1.82; P < 0.01). Conclusion: From 2006 to 2012 the use of PC in ESLD patients increased substantially; socioeconomic, geographical, and ethnic barriers to accessing PC were observed. (Hepatology 2017;66:1585–1591).

Use of Palliative Care in Patients With End-Stage COPD and Receiving Home Oxygen: National Trends and Barriers to Care in the United States

To investigate the use of palliative care (PC) in patients with end-stage COPD receiving home oxygen hospitalized for an exacerbation. A retrospective nationwide cohort analysis was performed, using the Nationwide Inpatient Sample. All patients ≥ 18 years of age with a diagnosis of COPD, receiving home oxygen, and admitted for an exacerbation were included. A total of 55,208,382 hospitalizations from the 2006-2012 Nationwide Inpatient Sample were examined. There were 181,689 patients with COPD, receiving home oxygen, and admitted for an exacerbation; 3,145 patients (1.7%) also had a PC contact. There was a 4.5-fold relative increase in PC referral from 2006 (0.45%) to 2012 (2.56%) (P< .01). Patients receiving PC consultations compared with those who did not were older (75.0 years [SD 10.9] vs70.6 years [SD 9.7]; P< .01), had longer hospitalizations (4.9days [interquartile range, 2.6-8.2] vs3.5days [interquartile range, 2.1-5.6]), and more likely to die in hospital (32.1%vs1.5%; P<.01). Race was significantly associated with referral to palliative care, with white patients referred more often than minorities (P< .01). Factors associated with PC referral included age (OR, 1.03; 95%CI, 1.02-1.04; P< .01), metastatic cancer (OR, 2.40; 95%CI, 2.02-2.87; P<.01), nonmetastatic cancer (OR, 2.75; 95%CI, 2.43-3.11; P< .01), invasive mechanical ventilation (OR, 4.89; 95%CI, 4.31-5.55; P< .01), noninvasive mechanical ventilation (OR,2.84; 95%CI, 2.58-3.12; P< .01), and Do Not Resuscitate status (OR, 7.95; 95%CI, 7.29-8.67; P< .01). The use of PC increased dramatically during the study period; however, PCcontact occurs only in a minority of patients with end-stage COPD admitted with an exacerbation.

A Scoring System for Identifying Severe Cases of Influenza-like Illness by Comorbidity and Age - A Nationwide Cohort Analysis

From 2008 to 2010, there were 319,775 ILI inpatient cases, of which 8.82% entered ICU and 3.83% died at hospital discharge. The significant comorbidity attributes varied in each age stratum: heart failure in any age, non-dialyzed renal insufficiency in any age, cancer in school-age children up to mid-age adults, tuberculosis in the elderly, stroke in adults, congenital anomaly in children and adolescents, transplant in school-age up to adolescents, or HIV in young adults. Comorbidity vector was (heart failure, non-dialyzed renal insufficiency, cancer, tuberculosis, stroke, congenital anomaly, transplant, HIV). Age vector was (1, 1, 6&lt;=age&lt;45, 75&lt;=age, 18&lt;=age&lt;65, 0&lt;age&lt;=18, 6&lt;=age&lt;18, 18&lt;=age&lt;45). Comorbidity score, the dot product of comorbidity vector and age vector, showed significant correlation with hospitalization cost (Spearman rho=0.1885, p&lt;0.0001), and with LOS (Spearman rho=0.1717, p&lt;0.0001). Its ROC area-under-curves (AUC) were 0.7454 with death and 0.6840 with ICU. The risk estimation model could facilitate us to address population measures for upcoming severe influenza epidemics, and further allocate resources optimally.

Appendectomy in the pediatric population-a German nationwide cohort analysis.

Meta-analyses indicate advantages of laparoscopic compared to open appendectomy. Nationwide analyses on results of laparoscopic appendectomy are scarce and studies from Germany are not available. This observational cohort study based on a nationwide insurance database was performed to analyze results of pediatric laparoscopic versus open appendectomy in general use. Data were extracted from the largest German statutory health insurance TK (∼9 million clients) in a 3-year period (2010-2012). All patients aged 4-17years with International Classification of Procedures in Medicine (ICPM) code "appendectomy" were included. Logistic regression analysis for the risk of a surgical complication within 180 postoperative days was performed. Appendectomy was performed in 8110 patients (52.6% male; 47.4% female) and conducted laparoscopically in 75.0% of the patients (conversion rate = 1.2%). Laparoscopic compared to open surgery was associated with a shorter length of hospital stay in both uncomplicated and complicated appendicitis. Patients with complicated appendicitis had lower readmission rates for surgical complications after laparoscopic appendectomy and logistic regression analysis confirmed a significantly lower risk of readmission for surgical complications after laparoscopic compared to open operation in adolescents. Pediatric surgeons operated 23.9% and general surgeons 76.1% of patients. Laparoscopy was less frequently used and the conversion rate was significantly higher in pediatric surgical departments. This first nationwide German cohort study confirms that laparoscopic appendectomy is associated with a less complicated postoperative course compared to open appendectomy, particularly in patients with complicated appendicitis. Pediatric surgeons used laparoscopy less frequently compared to general surgeons. Laparoscopic appendectomy should therefore be further promoted in pediatric surgical centers in Germany.