Nationwide Inpatient Survey Research Articles

Abstract P437: Trends in Outcomes, and Length and Costs of Hospitalization in Patients With Intracerebral Hemorrhage in United States

Background: It remains unclear whether there is any improvement in outcomes of patients with intracerebral hemorrhage over the last decade. Objective: To determine trends pertaining in-hospital outcomes in patients with intracerebral hemorrhage using nationally representative data. Methods: We determined the national estimates of intracerebral hemorrhage admissions from 2005 to 2014 and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data. The NIS is the largest all-payer inpatient care database in the US and contains data from 986 hospitals approximating a 20% stratified sample of US hospitals. Outcome was classified as none to minimal disability, moderate to severe disability, and death based on discharge destination. Results: In the 10-year period, there were 70,637 admissions for intracerebral hemorrhage (annual estimate 80804 in 2005 to 109930 in 2014). There was a significant reduction in in-hospital mortality in patients with intracerebral hemorrhage from 30% to 23% (trend test, p < 0.0001). There was a trend towards increase in proportion of patients with moderate to severe disability (trend test, p < 0.097). The mean length of hospitalization increased from 8.58 days to 9.23 days (trend test, p < 0.0001) and cost of hospitalization increased from $50532.1 to $110932.1 (trend test, p < 0.0001). Conclusions: The mortality in patients with intracerebral hemorrhage has decreased but there is increased rates of moderate to severe disability, length of hospitalization, and hospitalization cost over the last decade.

Higher odds of irritable bowel syndrome among hospitalized patients using cannabis: a propensity-matched analysis.

The endogenous cannabinoid system modulates many brain-gut and gut-brain physiologic pathways, which are postulated to be dysfunctional in irritable bowel syndrome (IBS). Herein, we examine the relationship between cannabis use disorder (CUD) and having IBS. After selecting patients aged 18 years and above from the 2014 Nationwide Inpatient Survey, we used the International Classification of Diseases, 9th ed. codes to identify individuals with CUD, IBS, and the established risk factors for IBS. We then estimated the crude and adjusted odds ratios of having a diagnosis of IBS with CUD and assessed for the interactions of CUD with other risk factors (SAS 9.4). We confirmed our findings in two ways: conducting a similar analysis on a previous Nationwide Inpatient Survey data (2012); and using a greedy algorithm to design a propensity-scored case-control (1 : 10) study, approximating a pseudorandomized clinical trial. Out of 4 709 043 patients evaluated, 0.03% had a primary admission for IBS and 1.32% had CUD. CUD was associated with increased odds of IBS [adjusted odds ratio: 2.03; 95% confidence interval (CI): 1.53-2.71]. CUD was related to higher odds for IBS among males compared with females (3.48; 1.98-6.12 vs. 1.48; 0.88-2.50), and Hispanics and Caucasians compared with Blacks (5.28; 1.77-15.76, 1.80; 1.02-3.18 vs. 1.80; 0.65-5.03). On propensity-matching, CUD was associated with 80% increased odds for IBS (1.82; 1.27-2.60). Our findings suggest that CUD is significantly associated with IBS among the general population. Males, Caucasians, and Hispanics might be more impacted by CUD associated IBS. Additional biomedical studies are required to elucidate this relationship.

Abstract WP31: A Comparison of Outcomes Associated With Mechanical Thrombectomy in Acute Ischemic Stroke Patients Performed Within and Outside Clinical Trials in the United States

Background: A discrepancy between characteristics of patients treated with mechanical thrombectomy in acute ischemic stroke patients within and outside clinical trials, particularly characteristics with direct impact on clinical outcome, may limit generalization of clinical trial results. The objective of this study was to identify differences in demographic and clinical characteristics and outcomes related to mechanical thrombectomy in patients treated in clinical trials and those treated outside clinical trials in a large national cohort. Methods: We determined the frequency of mechanical thrombectomy in acute ischemic stroke patients performed within and outside clinical trials and associated in-hospital outcomes using nationally representative data from the Nationwide Inpatient Survey data files from 2013 to 2015. We compared in-hospital mortality and discharge to home in patients who were treated within and outside the clinical trials. Results: Of the 23,375 patients who underwent mechanical thrombectomy, 430 (1.8%) underwent the procedure as part of a clinical trial. There was no difference in mean age of the patients treated with mechanical thrombectomy as part of a clinical trial than those treated with thrombectomy outside a clinical trial. The proportion of women was lower among patients treated with thrombectomy as part of a clinical trial. After adjusting for age, mechanical thrombectomy performed as part of a clinical trial was associated with lower rates of in-hospital mortality (odds ratio [OR]: 0.13; 95% confidence interval [CI]: 0.03-0.55; P = .002) and higher rates of discharge to home (OR, 2.5; 95% CI, 1.6-3.9; P = .003). Conclusions: Our results suggest that mechanical thrombectomy procedures performed as part of clinical trials were associated with lower rates of in-hospital mortality and higher rates of discharge home in the United States. These findings highlight the need for strategies that ensure appropriate adoption of mechanical thrombectomy to ensure that the benefits observed in clinical trials can be replicated in general practice.

In-Hospital Cerebrovascular Outcomes of Patients With Atrial Fibrillation and Cancer (from the National Inpatient Sample Database)

Limited data are available regarding the impact of cancer on cerebrovascular accidents in patients with atrial fibrillation (AF). We queried the Nationwide Inpatient Survey Database to identify patients who have diagnostic code for AF. We performed a 1:1 propensity matching based on the CHA2DS2VASc score and other risk factors between patients with AF who had lung, breast, colon, and esophageal cancer, and those who did not (control). The final cohort included a total of 31,604 patients. The primary outcome of in-hospital cerebrovascular accidents (CVA) was lower in the cancer group than in the control group (4% vs 7%, p < 0.001), but with only a weak association (ф = -0.067). In-hospital mortality was higher in the cancer group than in the control group (18% vs 11%, p < 0.001; ф = -0.099). A subgroup analysis according to cancer type showed similar results with a weak association with lower CVA in breast cancer (4% vs 7%; ф = -0.066, p < 0.001), lung cancer (4% vs 6%; ф = -0.062, p < 0.001), colon cancer (4% vs 6%; ф = -0.062, p < 0.001), and esophageal cancer (3% vs 7%; ф = -0.095, p < 0.001) compared with the control groups. A weak association with higher in-hospital mortality was demonstrated in lung cancer (20% vs 11%; ф = -0.127, p < 0.001), colon cancer (16% vs 11%; ф = -0.076, p < 0.001), and esophageal cancer (20% vs 12%; ф = -0.111, p < 0.001) compared with the control groups, but no significant difference between breast cancer and control groups in mortality (11% vs 11%; ф = -0.002, p = 0.888). In conclusion, in patients with AF, cancer diagnosis may not add a predictive role for in-hospital CVA beyond the CHADS2VASc score.

Cannabis Use Increases the Odds of Irritable Bowel Syndrome Among Hospitalized Patients: A Propensity Matched Analysis

Introduction: The Endogenous Cannabinnoid System (ECS) participates in many brain-gut and gutbrain pathologic pathways, all of which are dysfunctional in Irritable Bowel Syndrome (IBS). Herein, we investigate the association between the long-term cannabis use among individuals with cannabis use disorder (CUD) and a having a diagnosis of IBS. Methods: After selecting patients with age over 18 years from the 2014 Nationwide Inpatient Survey (NIS) and using the ICD-9 codes to identify individuals with CUD, IBS and the established risk factors for IBS, we estimated the crude and adjusted odds ratio (COR and AOR) of having a diagnosis of IBS with CUD. We then assessed for the interactions of CUD with other risk factors (SAS 9.4) and confirmed our findings in two ways: conducting a similar analysis of a prior (2012) NIS data; using a greedy algorithm to design a propensity-scored case-control (1:10) analysis. Results: Of 4,709,043 subjects, 0.03% had a primary admission for IBS and 1.32% had CUD. CUD was associated with increased odds of IBS (AOR: 2.03[1.53-2.71]). CUD was related to higher odds for IBS among males compared to females (3.48[1.98-6.12] vs. 1.48[0.88-2.50]), and Hispanics and Whites compared to Blacks (5.28[1.77-15.76], 1.80[1.02-3.18] vs. 1.80[0.65-5.03]). On propensity matching, CUD was associated with 80% increased odds for IBS (1.82[1.27-2.60]) Conclusion: Our findings suggest that CUD is associated with a diagnosis of IBS among the general population, and that males, Whites and Hispanics might be more sensitive to its impact on IBS. More epidemiological studies are required to elucidate this relationship.

Impact of Left Atrial Appendage Exclusion on Cardiovascular Outcomes in Patients With Atrial Fibrillation Undergoing Coronary Artery Bypass Grafting (From the National Inpatient Sample Database)

Left atrial appendage (LAA) exclusion is performed by some surgeons in patients with atrial fibrillation (AF) who undergo coronary artery bypass grafting (CABG). However, the available evidence regarding the efficacy and safety of this procedure remains mixed. We queried the Nationwide Inpatient Survey Database for the 10-year period from 2004 to 2013. Using International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis codes, we identified patients who had a diagnosis of AF and underwent a primary procedure of CABG with or without LAA exclusion. We then performed a 1:5 matching based on the CHA2DS2VASc score between patients who got LAA exclusion and those who did not (control group). The primary outcome was the incidence of in-hospital cerebrovascular events, whereas the secondary outcomes included in-hospital bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and mortality. Our analysis included a total of 15,114 patients. Patients who underwent LAA exclusion had significantly less incidence of cerebrovascular events (2.0% vs 3.1%, p = 0.002). However, LAA exclusion group had higher incidences of bleeding events (36.4% vs 21.3%, p <0.001), pericardial effusion (2.7% vs 1.2%, p <0.001), cardiac tamponade (0.6% vs 0.2%, p <0.001), and postoperative shock (1.2% vs 0.4%, p <0.001). LAA exclusion was associated with higher in-hospital mortality (1.6% vs 0.3%, p <0.001). Multivariate regression analysis showed that LAA exclusion was significantly associated with lower cerebrovascular accident events and higher in-hospital mortality. In conclusion, LAA exclusion in patients with AF undergoing CABG might be associated with a lower incidence of in-hospital cerebrovascular events. This benefit is offset by a higher incidence of higher bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and in-hospital mortality.

Cannabis use is associated with reduced prevalence of non-alcoholic fatty liver disease: A cross-sectional study.

Cannabis use is associated with reduced prevalence of obesity and diabetes mellitus (DM) in humans and mouse disease models. Obesity and DM are a well-established independent risk factor for non-alcoholic fatty liver disease (NAFLD), the most prevalent liver disease globally. The effects of cannabis use on NAFLD prevalence in humans remains ill-defined. Our objective is to determine the relationship between cannabis use and the prevalence of NAFLD in humans. We conducted a population-based case-control study of 5,950,391 patients using the 2014 Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Survey (NIS) discharge records of patients 18 years and older. After identifying patients with NAFLD (1% of all patients), we next identified three exposure groups: non-cannabis users (98.04%), non-dependent cannabis users (1.74%), and dependent cannabis users (0.22%). We adjusted for potential demographics and patient related confounders and used multivariate logistic regression (SAS 9.4) to determine the odds of developing NAFLD with respects to cannabis use. Our findings revealed that cannabis users (dependent and non-dependent) showed significantly lower NAFLD prevalence compared to non-users (AOR: 0.82[0.76–0.88]; p<0.0001). The prevalence of NAFLD was 15% lower in non-dependent users (AOR: 0.85[0.79–0.92]; p<0.0001) and 52% lower in dependent users (AOR: 0.49[0.36–0.65]; p<0.0001). Among cannabis users, dependent patients had 43% significantly lower prevalence of NAFLD compared to non-dependent patients (AOR: 0.57[0.42–0.77]; p<0.0001). Our observations suggest that cannabis use is associated with lower prevalence of NAFLD in patients. These novel findings suggest additional molecular mechanistic studies to explore the potential role of cannabis use in NAFLD development.

Understanding quality and satisfaction in public hospital services: A nationwide inpatient survey in Greece

Health services compared to the most of other sectors' customer services present some special traits, such as extreme complexity, co-production, and intangibility, while financial and human consequences of low quality are high. This study reports on the findings of a nationwide HCAHPS questionnaire survey conducted in Greece after the implementation of the health system reform due to the financial crisis regarding the factors determining inpatient satisfaction in public hospitals. HCAHPS data were initially analysed by factor analysis followed by an ordinal regression analysis, which aimed to identify the determinants with significant impact on inpatient satisfaction. The study results are consistent with prior research which indicated that the communication with nurses is the most salient predictor of overall patients’ satisfaction followed by communication with doctors. Moreover, certain patient (age and health status) and hospital institutional (type and location) characteristics also contribute significantly to patients’ perceived overall satisfaction. Hence, health quality improvement activities should consider the critical differences among patient subgroups and hospital types in order to fulfil consumer needs and preferences more effectively.

CORONARY ARTERY BYPASS GRAFT SURGERY AFTER ACUTE ST ELEVATION MYOCARDIAL INFARCTION: HOW EARLY IS TOO EARLY?

Background: The optimal timing of coronary artery bypass graft surgery (CABG) in patients presenting with acute ST elevation myocardial infarction (STEMI) is unclear. Methods: We reviewed the Nationwide Inpatient Survey database for all cases with a primary diagnosis of STEMI who underwent CABG

Abstract WMP56: Increase in Rate of Utilization of Withdrawal of Care in Acute Ischemic Stroke Patients in USA

Background: Early deaths are common in stroke, and most occur as a result of brain death or withdrawal of care when prognosis for recovery is believed to be poor. Survivors of severe stroke often have a gradual improvement in function but may experience significant disability, all of which may benefit from skilled palliative care. The objective of this study was to determine the rate of withdrawal of care in patients with ischemic stroke (IS) who underwent different treatment plans. Methods: We determined the frequency of “withdrawal of care” among patients with IS who received thrombolysis only, endovascular treatment only, both thrombolysis and endovascular treatment and neither thrombolysis nor endovascular treatment. We used Nationwide Inpatient Survey data files from 2006 -2011. Results: The annual rates of “withdrawal of care” increased from 0.9% in 2006 to 5.5% in 2011, p=&lt;0.0001 in IS patients treated with thrombolysis. The annual rates of “withdrawal of care” increased from 2.8% in 2006 to 9.0% in 2011, p=0.0006 in IS patients who underwent endovascular treatment. The annual rates of “withdrawal of care” increased from 2.0% in 2006 to 10.3% in 2011, p=0.0009 in IS patients treated with thrombolysis and endovascular treatment. The annual rates of “withdrawal of care” increased from 0.8% in 2006 to 3.0% in 2011, p=&lt;0.0001 in IS patients who neither received thrombolysis nor underwent endovascular treatment. Conclusions: We found a considerable increase in rate of withdrawal of care with aggressive treatment, which may be due to disease severity and/or patient/family preference. Prognostic models and clinical experience for severe stroke patients may be biased by frequent withdrawal of care, leading to errors in prognostication with significant consequences including premature withdrawal of care, suboptimal outcomes and higher risk of short-term mortality.

Abstract WMP115: Thrombolysis and Thrombectomy in Pediatric Ischemic Stroke

Introduction: Stroke is a devastating disease at any age. There are few studies on utility of intravenous thrombolysis (tPA) or intra-arterial thrombectomy (IAT) in pediatric acute ischemic stroke (AIS). Hypothesis: To describe and compare clinical outcomes of pediatric AIS patients who did and did not receive tPA+/-IAT. Methods: We retrospectively reviewed all pediatric AIS cases, aged 0-17, from the 2006-2010 Nationwide Inpatient Survey, a 20% stratified sample of all U.S. community hospitals. Demographics, outcomes, cost of stay, and comorbidities were assessed. Results: Overall, 20,587 patients were analyzed. Mean age was 6.0 years (SD 13.9); female 43.9%; white 47.7%. Of those, 198 patients received intervention: 169 tPA, 5 IAT, and 24 tPA+IAT. Treated patients were older (10.0 years vs 5.9 years, p&lt;0.0001). Mortality for pediatric AIS patients was 7.8%; 13.8% in tPA patients compared to 7.7% in the untreated. No deaths in the IAT group. Non-treated patients were more likely to be discharged home than those receiving tPA+/-IAT (67.8% vs. 47.5%, p&lt;0.0001). Cost for treated patients was higher ($200,346 vs. $123,015, p=0.01). Intracerebral hemorrhage (ICH) was more common in treated patients (10.1% vs. 3.8%, p&lt;0.0001). Comorbidities included Moyamoya disease (12.4%), cardiac valvular disease (6.6%), and sickle cell disease (6.5%). The treated group had higher prevalence of pneumonia/influenza (17.2% vs. 7.6%, p&lt;0.0001), procoagulable conditions (15.2% vs. 2%, p&lt;0.0001), and cardiac valvular disease (15.2% vs. 6.5%, p&lt;0.0001). Conclusions: In the pediatric AIS population, tPA was associated with increased mortality. Treatment with tPA+/-IAT was associated with decreased discharge home, increased cost, and higher prevalence of ICH. Prevalence of ICH is not explained by the presence of Moyamoya or sickle cell as those patients were less likely to receive treatment. Limitations of this study include small numbers of treated patients, lack of data on stroke severity or functional outcome, and data from years prior to newer thrombectomy devices. Studies of AIS treatment in adults cannot necessicarily be extrapolated given the difference in etiologies of pediatric AIS. Pediatric AIS is on the rise, so more research for effective treatment is necessary.

Changes in mortality on weekend versus weekday admissions for Acute Coronary Syndrome in the United States over the past decade

BackgroundWe assessed in-hospital mortality and utilization of invasive cardiac procedures following Acute Coronary Syndrome (ACS) admissions on the weekend versus weekdays over the past decade in the United States. MethodsWe used data from the Nationwide Inpatient Survey (2001–2011) to examine differences in all-cause in-hospital mortality between patients with a principal diagnosis of ACS admitted on a weekend versus a weekday. Adjusted and hierarchical logistic regression model analysis was then used to identify if weekend admission was associated with a decreased utilization of procedural interventions and increased subsequent complications as well. Results13,988,772 ACS admissions were identified. Adjusted mortality was higher for weekend admissions for Non-ST-Elevation Acute Coronary Syndromes [OR: 1.15, 95% CI, 1.14–1.16] and only somewhat higher for ST-Elevation Myocardial Infarction [OR: 1.03; 95% CI, 1.01–1.04]. Additionally, patients were significantly less likely to receive coronary revascularization intervention/therapy on their first day of admission [OR: 0.97, 95% CI: 0.96–0.98 and OR: 0.75, 95% CI: 0.75–0.75 for STEMI and NSTE-ACS respectively]. For ACS patients admitted during the weekend who underwent procedural interventions, in-hospital mortality and complications were higher as compared to patients undergoing the same procedures on weekdays. ConclusionFor ACS patients, weekend admission is associated with higher mortality and lower utilization of invasive cardiac procedures, and those who did undergo these interventions had higher rates of mortality and complications than their weekday counterparts. This data leads to the possible conclusion that access to diagnostic/interventional procedures may be contingent upon the day of admission, which may impact mortality.

The relation of depression to in-hospital outcomes among adults hospitalized for firearm-related injury

IntroductionFirearm injuries are a major health problem contributing to significant morbidity and mortality. Depression is associated with increased risk of adverse health outcomes in trauma patients and those hospitalized for serious disorders. We examined the relation between preexisting depression and adverse hospital outcomes and related injury severity among adult (>16-years) firearm hospitalizations (FH). MethodsUsing nationally representative Nationwide Inpatient Sample (2005 to 2011) and survey weighted multinomial logistic regression, we calculated odds ratios (OR) and 95% confidence intervals (95%CI) to determine the risk of care facility discharge and in-hospital mortality by pre-existing depression. ResultsPre-existing depression was associated with a 3-fold risk of discharge to care facility (OR=2.91, 95%CI=2.57-3.30) and a 2-fold risk of in-hospital mortality (OR=2.05, 95%CI=1.69-2.47). ORs for risk of care facility discharge compared to routine discharge associated with depression among assault/legal-FH, unintentional-FH, suicide-FH and undetermined-FH was 2.73 (95%CI=2.23-3.33), 1.90 (95%CI=1.50-2.41), 1.52 (95%CI=1.26-1.83) and 2.42 (95%CI=1.60-3.67), while risk of inhospital mortality was 0.17 (95%CI=0.05-0.54), 0.60 (95%CI=0.28-1.29), 0.79 (95%CI=0.63-0.98) and 0.74 (95%CI=0.36-1.52). LimitationsLack of information regarding re-hospitalization due to the cross-sectional data. CONCLUSION: Persons with depression who were hospitalized due to firearm-related injury were less likely to survive than those without depression, and those discharged alive were at higher risk of discharge to a facility. Depression was associated with greater risk of discharge to facility among all intents, and lower risk of in-hospital mortality among assault- and suicide-FH. These findings are important considering the increasing numbers of non-fatal firearm hospitalizations and the associated increase in healthcare expenditure.

Pheochromocytoma and paraganglioma in cyanotic congenital heart disease.

Aberrant cellular oxygen sensing is a leading theory for development of pheochromocytoma (PHEO) and paraganglioma (PGL). The objective of the study was to test the hypothesis that chronic hypoxia in patients with cyanotic congenital heart disease (CCHD) increases the risk for PHEO-PGL. We investigated the association between CCHD and PHEO-PGL with two complementary studies: study 1) an international consortium was established to identify congenital heart disease (CHD) patients with a PHEO-PGL diagnosis confirmed by pathology or biochemistry and imaging; study 2) the 2000-2009 Nationwide Inpatient Survey, a nationally representative discharge database, was used to determine population-based cross-sectional PHEO-PGL frequency in hospitalized CCHD patients compared with noncyanotic CHD and those without CHD using multivariable logistic regression adjusted for age, sex, and genetic PHEO-PGL syndromes. In study 1, we identified 20 PHEO-PGL cases, of which 18 had CCHD. Most presented with cardiovascular or psychiatric symptoms. Median cyanosis duration for the CCHD PHEO-PGL cases was 20 years (range 1-57 y). Cases were young at diagnosis (median 31.5 y, range 15-57 y) and 7 of 18 had multiple tumors (two bilateral PHEO; six multifocal or recurrent PGL), whereas 11 had single tumors (seven PHEO; four PGL). PGLs were abdominal (13 of 17) or head/neck (4 of 17). Cases displayed a noradrenergic biochemical phenotype similar to reported hypoxia-related PHEO-PGL genetic syndromes but without clinical signs of such syndromes. In study 2, hospitalized CCHD patients had an increased likelihood of PHEO-PGL (adjusted odds ratio 6.0, 95% confidence interval 2.6-13.7, P < .0001) compared with those without CHD; patients with noncyanotic CHD had no increased risk (odds ratio 0.9, P = .48). There is a strong link between CCHD and PHEO-PGL. Whether these rare diseases coassociate due to hypoxic stress, common genetic or developmental factors, or some combination requires further investigation.

Non-ST-Elevation Myocardial Infarction in Patients Undergoing Carotid Endarterectomy or Carotid Artery Stent Placement

Background and Purpose—The significance of non-ST–elevation myocardial infarction (NSTEMI) after carotid endarterectomy or carotid angioplasty and stent placement is unknown. We performed this study to identify the frequency of NSTEMI and impact on outcomes related to carotid endarterectomy or carotid artery stent placement in patients treated in a large national cohort. Methods—We determined the frequency of NSTEMI and associated in-hospital outcomes including mortality and composite of stroke, cardiac events, and mortality using data from the Nationwide Inpatient Survey from 2002 to 2009. Results—Of 1 083 688 patients who underwent carotid endarterectomy or carotid artery stent placement, 11 341 (1%) patients developed NSTEMI during hospitalization. After adjusting for constitutional variables and risk factors, NSTEMI was associated with higher rates of in-hospital mortality (odds ratio, 8.6; 95% confidence interval, 7.0–10.7; P≤0.0001) and composite end point of stroke, cardiac events, and death (odds ...

Trends in Outcome and Cost of Hospitalization of Elderly Myasthenia Gravis Patients from 1992 to 2009 Data from Nationwide Inpatient Survey (NIS)1997-2009 (P7.100)

Trends in Outcome and Cost of Hospitalization of Elderly Myasthenia Gravis Patients from 1992 to 2009 Data from Nationwide Inpatient Survey (NIS)1997-2009 (P7.100)

Trends in Outcome and Cost of Hospitalization of Adult Myasthenia Gravis. Data Analysis from Nationwide Inpatient Survey (NIS) from 1992 to 2009 (P7.105)

Trends in Outcome and Cost of Hospitalization of Adult Myasthenia Gravis. Data Analysis from Nationwide Inpatient Survey (NIS) from 1992 to 2009 (P7.105)

Abstract 166: Carotid Artery Stent Placement and Carotid Endarterectomy in Patients with Dialysis Dependent Renal Failure

Background: Patients with dialysis dependent renal failure (DDRF) have a high prevalence of carotid artery stenosis. These patients are excluded from clinical trials evaluating carotid artery stent placement (CAS) and carotid endarterectomy (CEA). Objective: To identify differences in demographic and clinical characteristics and outcomes related to CAS and CEA in DDRF and non DDRF patients in a large national cohort. Methods: We determined the frequency of CAS and CEA performed in DDRF and non DDRF patients and associated in-hospital outcomes using data from the Nationwide Inpatient Survey (NIS) data files from 2005 to 2011. All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. Results: Of the 8148 patients who underwent CAS, 693 (8.5%) were DDRF patients. After adjusting for age, gender, race, presence of dyslipidemia, congestive heart failure, and hypertension CAS performed in DDRF patients was associated with higher rates of in-hospital mortality(OR 3.7, 95% CI 1.0 - 13.9)(p=0.04) and moderate to severe disability (OR 1.7 , 95% CI 1.0 - 3.3)(p=0.05). Of the 43875 patients who underwent CEA, 3888 (8.8%) were DDRF patients. After adjusting for age, gender, race , presence of hypertension, congestive heart failure, dyslipidemia, nicotine dependence and alcohol abuse, CEA performed in DDRF patients was associated with higher rates of in-hospital mortality(OR 4.3, 95% CI 2.1 - 9.0)(p=&lt;.0001) and moderate to severe disability (OR 1.4 , 95% CI 1.1 - 1.8)(p=0.009). Conclusions: Both CAS and CEA were associated with higher rates of in-hospital mortality and moderate to severe disability in DDRF patients.

Non-ST–Elevation Myocardial Infarction in Patients Undergoing Carotid Endarterectomy or Carotid Artery Stent Placement

The significance of non-ST-elevation myocardial infarction (NSTEMI) after carotid endarterectomy or carotid angioplasty and stent placement is unknown. We performed this study to identify the frequency of NSTEMI and impact on outcomes related to carotid endarterectomy or carotid artery stent placement in patients treated in a large national cohort. We determined the frequency of NSTEMI and associated in-hospital outcomes including mortality and composite of stroke, cardiac events, and mortality using data from the Nationwide Inpatient Survey from 2002 to 2009. Of 1 083 688 patients who underwent carotid endarterectomy or carotid artery stent placement, 11 341 (1%) patients developed NSTEMI during hospitalization. After adjusting for constitutional variables and risk factors, NSTEMI was associated with higher rates of in-hospital mortality (odds ratio, 8.6; 95% confidence interval, 7.0-10.7; P≤0.0001) and composite end point of stroke, cardiac events, and death (odds ratio, 14.6; 95% confidence interval, 13.0-16.5; P≤0.0001). Our results contradict the notion that NSTEMI is a relatively benign entity after carotid endarterectomy or carotid artery stent placement.

The Emergence of Endovascular Treatment–Only Centers for Treatment of Intracranial Aneurysms in the United States

Because of the availability of new technology, the spectrum of endovascular treatment for intracranial aneurysms has expanded widely. Some centers have started offering only endovascular treatment to patients with intracranial aneurysms (endovascular treatment-only centers [ETOCs]). Our objective was to identify the proportion and outcome of patients treated at ETOCs in the United States. We determined the proportion of ETOCs in the United States using Nationwide Inpatient Survey data files from 2010. We compared short-term outcomes between ETOCs and endovascular and surgical treatment centers (ESTCs). The outcomes studied were none to minimal disability, moderate to severe disability, in-hospital mortality, postprocedure complications, length of stay, and hospital charges. Out of 85 hospitals performing endovascular treatment of unruptured aneurysms, 13 (15%) were categorized as ETOCs. Out of the 10,447 patients with unruptured aneurysms, 1245 (12%) were treated at ETOCs. ETOCs were more likely to be nonteaching hospitals (55% versus 45%, P=.02). The rates of in-hospital mortality (1.2% versus 1.8%) and none to minimal disability (88% versus 84%) were similar in patients treated at ETOCs and ESTC hospitals. The mean hospitalization charges were similar, but length of stay (4±7 days versus 6±10 days, P<.0001) was significantly shorter among patients treated at ETOCs. Only 2.7% patients required secondary neurosurgical procedures at the ETOCs compared with 5.8% in ESTCs (P=.09). The recent emergence of ETOCs and provision of treatment with comparable outcomes and shorter length of stay at these hospitals may change the pattern of intracranial aneurysm treatment in the United States.