Non-elective Admissions Research Articles

COVID-19 and prevalence of venous thromboembolism among cancer patients: A nationwide inpatient sample analysis.

e18839 Background: Cancer, as well as immunosuppression from chemotherapy, aggravates thromboembolism risk. The risk is likely amplified in an additive fashion with COVID-19 infection, which confers a higher risk of VTE risk with viral sepsis, endothelial inflammation, and microthrombi formation. Numerous studies have shown the heightened risk of pulmonary embolism among severe COVID-19 patients. We sought to evaluate further the extent of COVID-19-associated coagulopathy and associated outcomes. Methods: National Inpatient Sample 2020 was used to identify non-elective hospitalizations of patients with a secondary diagnosis of any cancer. These were stratified into two cohorts based on the presence of the primary diagnosis of COVID-19. Primary outcomes include venous thromboembolism, PE, and VTE without PE in cancer patients with and without Covid-19 infection. The secondary outcomes examined were in-patient mortality, the average length of stay (LOS), and total hospital charge (THC). Multivariate analysis was performed to obtain the odds ratio. All weighted analysis was conducted through STATA 17. Results: Out of 1,734,735 non-elective admissions of patients with cancer, 36,295 (2%) were admitted for COVID-19. Our analysis showed statistically non-significant increased odds of venous thromboembolism(aOR:1.09 CI 0.99-1.20) in cancer patients with COVID. There was, however, a significant increase in the odds of pulmonary embolism(aOR 1.7, CI: 1.51- 1.91) among cancer patients with Covid-19. There were decreased odds of VTE without PE(aOR: 0.67 CI: 0.57-0.78). There was a statistically significant increase in odds of mortality (aOR: 2.8 CI: 2.63-3.0), length of stay(aOR:1.85 CI: 1.65- 2.05), total hospital charges($83,201 vs. $78,869 p: < 0.01) in cancer patients with COVID-19 compared to cancer patients without COVID-19. Conclusions: This study shows that COVID-19 in cancer patients has deleterious effects, including an increased risk of pulmonary embolism and poor in-hospital outcomes. The finding of a lower incidence of non-PE VTE in patients with cancer is likely related to limitations with coding in NIS, in which lower complexity codes might be omitted in patients with multiple diagnoses. With significantly increased mortality and economic burden, these findings emphasize the significance of thrombotic prophylaxis and vaccination in cancer patients. [Table: see text]

Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-centre study

BackgroundStress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines.MethodsData on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level.ResultsStress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384–1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually.ConclusionThis study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.

Human Immunodeficiency Virus and Hepatitis C Virus-related Disparities in Undergoing Emergency General Surgical Procedures in the United States, 2016-2019.

To determine whether people living with human immunodeficiency virus (PLWHIV) and people living with hepatitis C virus (PLWHCV) experience inequities in receipt of emergency general surgery (EGS) care. PLWHIV and PLWHCV face discrimination in many domains; it is unknown whether this extends to the receipt of EGS care. Using data from the 2016 to 2019 National Inpatient Sample, we examined 507,458 nonelective admissions of adults with indications for one of the 7 highest-burden EGS procedures (partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, or laparotomy). Using logistic regression, we evaluated the association between HIV/HCV status and the likelihood of undergoing one of these procedures, adjusting for demographic factors, comorbidities, and hospital characteristics. We also stratified analyses for the 7 procedures separately. After adjustment for covariates, PLWHIV had lower odds of undergoing an indicated EGS procedure [adjusted odds ratio (aOR): 0.81; 95% CI: 0.73-0.89], as did PLWHCV (aOR: 0.66; 95% CI: 0.63-0.70). PLWHIV had reduced odds of undergoing cholecystectomy (aOR: 0.68; 95% CI: 0.58-0.80). PLWHCV had lower odds of undergoing cholecystectomy (aOR: 0.57; 95% CI: 0.53-0.62) or appendectomy (aOR: 0.76; 95% CI: 0.59-0.98). PLWHIV and PLWHCV are less likely than otherwise similar patients to undergo EGS procedures. Further efforts are warranted to ensure equitable access to EGS care for PLWHIV and PLWHCV.

Health gains from home energy efficiency measures: The missing evidence in the UK net-zero policy debate

ObjectivesThis study examined the health gains from a programme of external wall insulation works to homes in south-west Scotland, and in particular the impact upon hospitalisations for respiratory and cardiovascular conditions. Furthermore, to consider how evidence on health outcomes could form part of the debate around actions to meet net-zero goals in the UK. Study designThis was a two-part study. Part one involved before-and-after interviews with 229 recipient households. The second part comprised an observational study of hospital admissions in 184 postcode areas. MethodsAcross three years, interviews collected thermal comfort and self-reported health data(Sf-36) in the winter months prior to installation, and again in follow-up interviews the next winter. Standarised monthly data on non-elective admissions for each set of conditions were compared between the intervention postcodes and the wider health board area over a ten year period. ResultsFollowing receipt of wall insulation, inability to achieve thermal comfort in winter reduced by two-thirds. Improvements in thermal comfort were associated with gains in physical health scores. Relative standardised admissions fell in the treatment areas, remaining lower than the district-wide standardised rate for the majority of a five year period, this effect ending during the Covid-19 pandemic. The impact on admissions was greater for respiratory conditions than for cardiovascular conditions. ConclusionA weak policy commitment to energy efficiency could be strengthened with further evidence of the cost-savings and reduced hospital bed demand resulting from insulations works. The potential health gain may also encourage more home owners to participate.

Prevalence and risk of type 2 myocardial infarction (T2MI) in adults with depression and its impact on in-hospital outcomes: a nationwide population-based analysis in the USA (2019)

Abstract Funding Acknowledgements Type of funding sources: None. Background Type 2 myocardial infarction (T2MI) is an ischaemic myocardial injury in the context of oxygen supply/demand mismatch in the absence of a primary coronary event. However, though there is a rising prevalence of depression and its potential association with T1MI, data remains non-existent to evaluate the association with T2MI. Therefore, we aim to identify the prevalence and risk of T2MI in adults with depression and its impact on the in-hospital outcomes. Methods We queried the National Inpatient Sample (2019) to identify T2MI hospitalizations using ICD-10 codes in hospitalized adults ( ≥18 years). In addition, we compared sociodemographics and comorbidities in the T2MI cohort with vs. without comorbid depression. Finally, we used multivariate regression analysis to study the odds of T2MI hospitalizations with vs. without depression and in-hospital outcomes (all-cause mortality, cardiogenic shock, cardiac arrest, and stroke); adjusting for confounders. Statistical significance was achieved with p-value of <0.05. Results There were 331,145 adult T2MI hospitalizations after excluding T1MI (median age 73 years, 52.8% male, 69.9% white); 41,405 (12.5%) had depression, the remainder; 289,740 did not have depression. Multivariate analysis revealed lower odds of T2MI in patients with depression vs without (aOR 0.88, 95% CI 0.86-0.90, p= 0.001).There was equal prevalence of prior MI with any revascularization and similar prevalence of peripheral vascular disease in cohort with depression vs without depression. There is a greater prevalence of stroke in patients with depression 10.1% vs those without 8.6 %. There was a slightly higher prevalence of hyperlipidaemia in patients with depression vs without depression; (56.5% vs 48.9%), as well as obesity (21.3% vs 17.9%) There was generally equal prevalence of HTN and T2DM in both cohorts. There was no significant difference in the frequency of elective and non-elective admissions between cohorts. Patients with depression vs without depression also showed a lower risk of all-cause mortality (aOR 0.75, 95%CI 0.67-0.83, p= 0.001), Cardiogenic shock (aOR 0.65, 95%CI 0.56-0.76, p= 0.001), Cardiac arrest (aOR 0.77, 95%CI 0.67-0.89, p= 0.001) as well as Stroke (aOR 0.79, 95%CI 0.70-0.89, p= 0.001). Conclusions This study revealed a significantly lower risk of T2MI in patients with depression vs. without depression. The data also showed a significant decrease in adverse in-hospital outcomes such as all-cause mortality, cardiogenic shock, cardiac arrest and stroke in patients with depression vs. without depression. Further prospective studies are warranted to assess the impact of depression on other in-hospital outcomes as well as the impact of medication, its duration and serotonin levels on T2MI.

782 The Effect of Medical Comorbidites on Mortality in Burn Patients

Abstract Introduction Age, percent total burn surface area (TBSA) burn, and presence of inhalation injury have been well accepted as prognostic factors associated with burn injury. However, there may be additional comorbidities that affect mortality to consider. Recently published data include comorbidities specifically in the elderly population or focus on a specific comorbidity. As such, this analysis sought to identify comorbidities with a more comprehensive approach while focusing on the adult population. Methods The National Inpatient Sample was queried for all patients with age 18-65 years with ICD-9 codes for total body surface area (TBSA) burn ≥ 20% and non-elective admissions. Years included were 2013- third quarter of 2015. Age, race, comorbidities and mortality were recorded. Cases with missing data for mortality were excluded. Statistical analysis was done with Chi-Square testing. Mortality was then used to perform a binary logistic regression using these variables. Results There were 5545 weighted cases. The median age was 41.0 years (IQR 29-52 years). Mortality was 14.7%. The presence of AIDS, chronic blood loss anemia, chronic pulmonary disease, congestive heart failure, peptic ulcer disease (excluding bleeding), peripheral vascular disease, renal failure, rheumatoid arthritis/collagen vascular disease, and solid tumor without metastasis were not found to be statistically significant. The significant variables were then entered into a binary regression model on mortality. For the regression analysis, age, gender and race were also included. Age and race were statistically significant (p < 0.001 for both), while gender was not (p=0.072). While significant on univariate analysis, alcohol abuse (p=0.059), diabetes with chronic complications (p=0.244), metastatic cancer (p=0.999), psychoses (p=0.053) and valvular disease (p=0.998) were no longer significant on multivariate analysis. The results of the significant comorbidities are listed in the table. In those who died, there were increased odds of having coagulopathy, uncomplicated diabetes, liver disease, paralysis, pulmonary circulation disorders and obesity. Conclusions Identification of these significant comorbidities potentially highlights the need for updated models to assist clinicians in determining risk of mortality in burn patients. Theses comorbidities also point to the importance of resources for primary care physicians to optimize these patient populations and potentially minimize the risk of complications should patients become injured. Applicability of Research to Practice

43 Home alone: Factors associated with discharge with Home Health

Abstract Introduction Burn patients are discharged home with ongoing wound care needs. Many obtain assistance at home with home health services. There are few published studies that review factors associated with obtaining these services upon discharge. As such, this study aims to identify patient-specific and hospital-specific factors that may contribute to being discharged under the care of home health services. Methods The National Inpatient Sample was queried for all patients with age ≥ 18 years with ICD-9 codes for total body surface area (TBSA) burn ≥ 20% and non-elective admissions. Patients were further selected for those discharge home (routine) and those discharged under care of organized home health service organization. Years included were 2013- third quarter of 2015. Age, race, percent TBSA burn, demographic data, hospital factors and mortality were recorded. Statistical analysis was done with Chi-Square testing. Discharge was then used to perform a binary logistic regression using the significant variables. Results There were 3245 weighted cases. Females accounted for 21.3% of the population. Of these encounters, 22.8% were discharged home with home health services. The average age of those without home health was 39.61 ± 13.59 years, versus 44.75 ± 15.92 years for those with home health (p< 0.001). Gender, percent TBSA burn, quartile of median household income of residents in the patient's ZIP Code, patient insurance, use of alcohol or drugs (p< 0.001), hospital bed size, hospital region, and hospital control/ownership (p< 0.001) were found to be statistically significant on univariate analysis. Discharge with home health services was then used to perform a multivariate analysis with the statistically significant factors. This found age (p< 0.001), and alcohol or drug use (p< 0.001) to be significant factors. The additional statistically significant factors are listed in Table 1. Those with home health services were less likely to have history of drug or alcohol use (OR 0.550 [IQR 0.424-0.713]) but more likely to be older, and to have Government insurance (OR 2.899 [IQR 2.096-4.009]) or Private insurance (OR 2.398 [IQR 1.713-3.356]), compared to self pay. There is also significant variability based on hospital region. Conclusions Multiple patient-specific and hospital-specific factors may influence the possibility of burn patient being discharged home with home health services. It appears that patients who may benefit from these services were in fact captured as higher rates of home health services were noted among those with government insurance and within the lowest quartile of income based on patient zip codes. However, there seems to be room for improved services across the nation as there is great variability based on region. Applicability of Research to Practice Discuss factors associated with patients being discharged home with home health services. Identify areas of possible improvement to maximize access to these services for all burn patients.

Center-Level Variation in Failure to Rescue After Pediatric Cardiac Surgery

BackgroundAlthough failure to rescue (FTR) is increasingly recognized as a quality metric, studies in congenital cardiac surgery remain sparse. Within a national cohort of children undergoing cardiac operations, we characterized the presence of center-level variation in FTR and hypothesized a strong association with mortality but not complications. MethodsAll children undergoing congenital cardiac operations were identified in the 2013 to 2019 Nationwide Readmissions Database. FTR was defined as in-hospital death after cardiac arrest, ventricular tachycardia/fibrillation, prolonged mechanical ventilation, pneumonia, stroke, venous thromboembolism, or sepsis, among other complications. Hierarchical models were used to generate hospital-specific, risk-adjusted rates of mortality, complications, and FTR. Centers in the highest decile of FTR were identified and compared with others. ResultsOf an estimated 74,070 patients, 1.9% died before discharge, at least 1 perioperative complication developed in 43.0%, and 4.1% experienced FTR. After multilevel modeling, decreasing age, nonelective admission, and increasing operative complexity were associated with greater odds of FTR. Variations in overall mortality and FTR exhibited a strong, positive relationship (r = 0.97), whereas mortality and complications had a negligible association (r = −0.02). Compared with others, patients at centers with high rates of FTR had similar distributions of age, sex, chronic conditions, and operative complexity. ConclusionsIn the present study, center-level variations in mortality were more strongly explained by differences in FTR than complications. Our findings suggest the utility of FTR as a quality metric for congenital heart surgery, although further study is needed to develop a widely accepted definition and appropriate risk-adjustment models.

P-001 RISK FACTORS, HEALTHCARE RESOURCE USE AND COSTS ASSOCIATED WITH INCISIONAL HERNIA REPAIR IN ENGLAND USING HOSPITAL EPISODE STATISTICS

Abstract Aim To evaluate the burden of incisional hernia (IH) to patients and healthcare services in England. Material & Methods We conducted a retrospective observational study in Hospital Episode Statistics including adult patients who underwent stoma, transplant, or aortic surgery (index) between 01/04/2017 and 31/03/2022. We followed patients for development of incisional (including parastomal) hernia necessitating repair within 2 years post-index operation, describing patients by surgery type, number of comorbidities (prior abdominal surgery, chronic lung disease, diabetes, immunosuppressed status, obesity, smoker), and financial year. We evaluated costs associated with inpatient, outpatient, and Accident & Emergency attendances within 2 years post-index operation using National Health Service reference costs. Results Of 430,339 patients (132,584 stoma, 3,247 transplant, 294,508 aortic surgery), 24,949 developed IH requiring repair (6.74% overall, 13.74% stoma, 5.51% transplant, 2.80% aortic surgery). Operative IH was observed in 11.46%, 5.54%, and 1.94%, for patients with 0–2 comorbidities following stoma, transplant, and aortic surgery, respectively; for patients with 5–6 comorbidities, 29.70%, 5.97%, and 6.91% underwent repair of IH. For all years, costs were higher for patients with IH versus those without IH. Costs varied by surgery type and number of comorbidities and were driven by non-elective admissions. The difference in mean total costs for IH versus non-IH following surgery performed in 2017 was £16,350 for stoma, £19,268 for transplant, and £54,518 for aortic surgery. Conclusions Rates of IH repair increase alongside the number of comorbidities. A large number of patients require IH repair within 2 years of surgery, increasing the cost of care.

Trends in Childhood Oncology Admissions to ICUs in Australia and New Zealand.

There are few robust, national-level reports of contemporary trends in pediatric oncology admissions, resource use, and mortality. We aimed to describe national-level data on trends in intensive care admissions, interventions, and survival for children with cancer. Cohort study using a binational pediatric intensive care registry. Australia and New Zealand. Patients younger than 16 years, admitted to an ICU in Australia or New Zealand with an oncology diagnosis between January 1, 2003, and December 31, 2018. None. We examined trends in oncology admissions, ICU interventions, and both crude and risk-adjusted patient-level mortality. Eight thousand four hundred ninety admissions were identified for 5,747 patients, accounting for 5.8% of PICU admissions. Absolute and population-indexed oncology admissions increased from 2003 to 2018, and median length of stay increased from 23.2 hours (interquartile range [IQR], 16.8-62 hr) to 38.8 hours (IQR, 20.9-81.1 hr) ( p < 0.001). Three hundred fifty-seven of 5,747 patients died (6.2%). There was a 45% reduction in risk-adjusted ICU mortality, which reduced from 3.3% (95% CI, 2.1-4.4) in 2003-2004 to 1.8% (95% CI, 1.1-2.5%) in 2017-2018 ( p trend = 0.02). The greatest reduction in mortality seen in hematological cancers and in nonelective admissions. Mechanical ventilation rates were unchanged from 2003 to 2018, while the use of high-flow nasal prong oxygen increased (incidence rate ratio, 2.43; 95% CI, 1.61-3.67 per 2 yr). In Australian and New Zealand PICUs, pediatric oncology admissions are increasing steadily and such admissions are staying longer, representing a considerable proportion of ICU activity. The mortality of children with cancer who are admitted to ICU is low and falling.

Prevalence and outcomes of frailty in unplanned hospital admissions: a systematic review and meta-analysis of hospital-wide and general (internal) medicine cohorts.

Guidelines recommend routine frailty screening for all hospitalised older adults to inform care decisions, based mainly on studies in elective or speciality-specific settings. However, most hospital bed days are accounted for by acute non-elective admissions, in which the prevalence and prognostic value of frailty might differ, and uptake of screening is limited. We therefore did a systematic review and meta-analysis of frailty prevalence and outcomes in unplanned hospital admissions. We searched MEDLINE, EMBASE and CINAHL up to 31/01/2023 and included observational studies using validated frailty measures in adult hospital-wide or general medicine admissions. Summary data on the prevalence of frailty and associated outcomes, measurement tools, study setting (hospital-wide vs general medicine), and design (prospective vs retrospective) were extracted and risk of bias assessed (modified Joanna Briggs Institute checklists). Unadjusted relative risks (RR; moderate/severe frailty vs no/mild) for mortality (within one year), length of stay (LOS), discharge destination and readmission were calculated and pooled, where appropriate, using random-effects models. PROSPERO CRD42021235663. Among 45 cohorts (median/SD age=80/5 years; n=39,041,266 admissions, n=22 measurement tools) moderate/severe frailty ranged from 14.3% to 79.6% overall (and in the 26 cohorts with low-moderate risk of bias) with considerable heterogeneity between studies (phet < 0.001) preventing pooling of results but with rates <25% in only 3 cohorts. Moderate/severe vs no/mild frailty was associated with increased mortality (n=19 cohorts; RR range=1.08-3.70), more consistently among cohorts using clinically administered tools (n=11; RR range=1.63-3.70; phet=0.08; pooled RR=2.53, 95% CI=2.15-2.97) vs cohorts using (retrospective) administrative coding data (n=8; RR range=1.08-3.02; phet < 0.001). Clinically administered tools also predicted increasing mortality across the full range of frailty severity in each of the six cohorts that allowed ordinal analysis (all p<0.05). Moderate/severe vs no/mild frailty was also associated with a LOS >8 days (RR range=2.14-3.04; n=6) and discharge to a location other than home (RR range=1.97-2.82; n=4) but was inconsistently related to 30-day readmission (RR range=0.83-1.94; n=12). Associations remained clinically significant after adjustment for age, sex and comorbidity where reported. Frailty is common in older patients with acute, non-elective hospital admission and remains predictive of mortality, LOS and discharge home with more severe frailty associated with greater risk, justifying more widespread implementation of screening using clinically administered tools. None.

PO-02-028 NEGATIVE EFFECTS OF COVID-19 ON THE IMPLANTATION RATE OF CARDIAC RESYNCHRONIZATION THERAPY WITH DEFIBRILLATOR DEVICE.

Coronavirus-19 (COVID-19) pandemic drastically changed the landscape of the US medical system. Total surgical procedure volume declined across all specialties, primarily in elective procedures. Multiple task forces promoted the cancellation of nonurgent elective procedures, including the implantation of a Cardiac Resynchronization Therapy Defibrillator (CRT-D) in stable patients during the pandemic. The effect of COVID-19 on the rate of CRT-D implantation is poorly understood. We aim to explore the impact of the COVID-19 pandemic on CRT-D insertion rates, along with negative outcomes related to delays in care. We conducted a retrospective analysis using the National Inpatient Sample (NIS) database for patient encounters involving the insertion of CRT-D between 2017 & 2020. Variables were identified using their ICD-10 codes. Admissions were included if the patient was at least 18 years of age, presenting for a non-elective admission, had a primary diagnosis of hypertensive heart disease, hypertensive heart, and chronic kidney disease, or heart failure (ICD-10 codes I11, I13, I50), and underwent insertion of a CRT-D (ICD-10 code 0JH**9*). Between 2017 and 2020, CRT-D devices were inserted during 23,635 admissions. On average, 6,198 devices were implanted yearly from 2017 to 2019, with only 5,040 being implanted in 2020. CRT-D implant rates dropped below their previous 3-year average in every region of the US during 2020 (Figure 1). Additionally, the highest average death rate at 13.89%, but this difference was statistically insignificant (adjusted Wald test p=0.767), and COVID-19 was not associated with an increased risk of inpatient mortality (OR 0.22, 95% CI 0.03-1.82, p=0.162). Blacks were disproportionately affected by a reduction in CRT-D procedures for this demographic in 2020 as compared to other races. COVID-19 pandemic has affected all facets of the healthcare system, especially surgical volume rates. Consistent with many other procedures, CRT-D procedures significantly decreased in 2020 following multiple task force recommendations to postpone nonurgent procedures in the setting of rampant COVID-19 infections. To our knowledge, this is the first retrospective study highlighting the trend of decreased rates of CRT-D implantation as a response to the COVID-19 pandemic.

Regional Disparities of Cardiovascular Risk Factors and Major Cardiovascular Events in Non-electively Hospitalized Young Adults.

Cardiovascular diseases contribute to considerable morbidity and mortality in the USA. We sought to establish regional disparities across the nation contributing to cardiovascular disease (CVD) among non-elective young adult hospitalizations. The National Inpatient Sample (2019) was utilized to identify the incidence of non-elective hospitalizations among young adults (18-44 yrs) and analyze the burden of CVD risk factors and outcomes (MACCE; all-cause mortality, AMI, cardiac arrest and stroke) in different US regions. A total of 5,833,930 (median age 32 [26-37] years) non-elective admissions were recorded; plurality from the south (39.6%). Most admissions were white (51.4%) and female (65.5%) amid all regions. The burden of CVD risk factors was significantly higher in the South followed by the Mid-west regions. The South had the highest and the Northeast had the lowest rates of MACE (2.9% vs 2.3%) and stroke (1.0% vs 0.8%). The risk of AMI was high for the south and Midwest regions (1.1%). All-cause mortality was highest in South and West regions (0.7%). Multivariate adjusted odds for these cardiovascular events were higher in the West (aOR 1.22; 95%CI 1.12-1.33) followed by South (aOR 1.16; 95%CI 1.07-1.26) regions. This population-based study assessing non-elective admissions in the young revealed a higher burden of CVD risk factors and rate of MACCE in the South compared to other areas of the USA. Regional policies should be tailored to the local CVD risk burden.

National Documentation and Coding Practices of Noncompliance: The Importance of Social Determinants of Health and the Stigma of African-American Bias.

Patient records serve many purposes, one of which includes monitoring the quality of care provided that they can be analyzed through coding and documentation. Z-codes can provide additional information beyond a specific clinical disorder that may still warrant treatment. Social Determinants of Health have specific Z-codes that may help clinicians address social factors that may contribute to patients' health care outcomes. However, there are Z-codes that specify patient noncompliance which has a pejorative connotation that may stigmatize patients and prevent clinicians from examining nonadherence from a social determinant of health perspective. A retrospective cross-sectional study was performed to examine the associations of patient and encounter characteristics with the coding of patient noncompliance. Included in the study were all patients >18 years of age who were admitted to hospitals participating in the Vizient Clinical Data Base (CDB) between January 1, 2019 and December 31, 2019. Almost 9 million US inpatients were included in the study. Of those, 6.3% had a noncompliance Z-code. Use of noncompliance Z-codes was associated with the following odds estimate ratio in decreasing order: the presence of a social determinant of health (odds ratio [OR], 4.817), African American race (OR, 2.010), Medicaid insurance (OR, 1.707), >3 chronic medical conditions (OR, 1.546), living in an economically distressed community (OR, 1.320), male gender (OR, 1.313), nonelective admission status (OR, 1.245), age <65 years (OR, 1.234). More than 1 in 15 patient hospitalizations had a noncompliance code. Factors associated with these codes are difficult, if not impossible, for patients to modify. Disproportionate representation of Africa-Americans among hospitalizations with noncompliance coding is concerning and urgently deserves further exploration to determine the degree to which it may be a product of clinician bias, especially if the term noncompliance prevents health care providers from looking into socioeconomic factors that may contribute to patient nonadherence.

Evaluation of systemic impact of tricuspid regurgitation: an appleal for the notion of tricuspid regurgitation.

Evaluation of systemic impact of tricuspid regurgitation: an appleal for the notion of tricuspid regurgitation.

Interhospital transfer of pediatric patients with malignant brain tumor not associated with increased mortality, but safe routine discharge.

Interhospital transfer (IHT) to obtain a higher level of care for pediatric patients requiring neurosurgical interventions is common. Pediatric patients with malignant brain tumors often require subspecialty care commonly provided at specialized centers. The authors aimed to assess the impact of IHT in pediatric neurosurgical patients with malignant brain tumors to identify areas of improvement in treatment of this patient population. Pediatric patients (age < 19 years) with malignant primary brain tumors undergoing craniotomy for resection between 2010 and 2018 were retrospectively identified in the Nationwide Readmissions Database. Patient and hospital data for each index admission provided by the Nationwide Readmissions Database was analyzed by univariate and multivariate analyses. Further analysis evaluated association of IHT on specific patient- or hospital-related characteristics. In a total of 2279 nonelective admissions for malignant brain tumors in pediatric patients, the authors found only 132 patients (5.8%) who underwent IHT for a higher level of care. There is an increased likelihood of transfer when a patient is younger (< 7 years old, p = 0.006) or the disease process is more severe, as characterized by higher pediatric complex chronic conditions (p = 0.0004) and increased all patient refined diagnosis-related group mortality index (p = 0.02). Patients who are transferred (OR 1.87, 95% CI 1.04-3.35; p = 0.04) and patients who are treated at pediatric centers (OR 6.89, 95% CI 4.23-11.22; p < 0.0001) are more likely to have a routine discharge home. On multivariate analysis, transfer status was not associated with a longer length of stay (incident rate ratio 1.04, 95% CI 0.94-1.16; p = 0.5) or greater overall costs per patient ($20,947.58, 95% CI -$35,078.80 to $76,974.00; p = 0.50). Additionally, IHT is not associated with increased likelihood of death or major complication. IHT has a significant role in the outcome of pediatric patients with malignant brain tumors. Transfer of this patient population to hospitals providing subspecialized care results in a higher level of care without a significant burden on overall costs, risks, or mortality.

An Analysis of 30-Day Readmissions of Surgically Managed Hiatal Hernia in the United States, 2010 to 2018

Background: Longitudinal national data on 30-day readmissions after hiatal hernia (HH) repair has not yet been fully explored. Methods: Data was obtained from the National Readmissions Database (NRD) for patients undergoing HH repair between 2010 and 2018. Univariable and multivariable logistic regression analyses reported with odds ratio (OR) and 95% confidence intervals (CI) were performed to identify factors associated with 30-day readmission. Interventions and procedures performed during readmission were extracted using International Classification of Disease (ICD)-9 and ICD-10 codes. Results: A total of 113 928 patients met inclusion criteria. Of these patients, 7492 (6.58%) were readmitted within 30 days of their initial hiatal hernia repair. Factors associated with readmission included age, diagnosis of frailty, non-elective admission for the index procedure and open approach. The median total cost of the readmission event was $29 845. On multivariable logistic regression, factors associated with 30-day readmission included frailty (OR = 1.17, P = .04), index admission status (non-elective, OR = 1.18, P &lt; .001), Medicare (OR = 1.27, P &lt; .001) or Medicaid insurance (OR = 1.36, P &lt; .001), repair approach (open, OR = 1.14, P &lt; .001), and initial length of stay (OR = 1.03, P &lt; .001). On readmission, patients underwent a range of procedures, but only a small proportion required hiatal hernia re-repair. Conclusion: There are notable demographic differences between the non-readmitted and readmitted cohorts, as well as specific risk factors associated with readmission within 30 days of hiatal hernia repair. Further research is necessary determine population-specific methods to prevent readmission in the highest risk cohort.

Distinct Subtypes of Hepatorenal Syndrome and Associated Outcomes as Identified by Machine Learning Consensus Clustering

The utilization of multi-dimensional patient data to subtype hepatorenal syndrome (HRS) can individualize patient care. Machine learning (ML) consensus clustering may identify HRS subgroups with unique clinical profiles. In this study, we aim to identify clinically meaningful clusters of hospitalized patients for HRS using an unsupervised ML clustering approach. Consensus clustering analysis was performed based on patient characteristics in 5564 patients primarily admitted for HRS in the National Inpatient Sample from 2003-2014 to identify clinically distinct HRS subgroups. We applied standardized mean difference to evaluate key subgroup features, and compared in-hospital mortality between assigned clusters. The algorithm revealed four best distinct HRS subgroups based on patient characteristics. Cluster 1 patients (n = 1617) were older, and more likely to have non-alcoholic fatty liver disease, cardiovascular comorbidities, hypertension, and diabetes. Cluster 2 patients (n = 1577) were younger and more likely to have hepatitis C, and less likely to have acute liver failure. Cluster 3 patients (n = 642) were younger, and more likely to have non-elective admission, acetaminophen overdose, acute liver failure, to develop in-hospital medical complications and organ system failure, and to require supporting therapies, including renal replacement therapy, and mechanical ventilation. Cluster 4 patients (n = 1728) were younger, and more likely to have alcoholic cirrhosis and to smoke. Thirty-three percent of patients died in hospital. In-hospital mortality was higher in cluster 1 (OR 1.53; 95% CI 1.31-1.79) and cluster 3 (OR 7.03; 95% CI 5.73-8.62), compared to cluster 2, while cluster 4 had comparable in-hospital mortality (OR 1.13; 95% CI 0.97-1.32). Consensus clustering analysis provides the pattern of clinical characteristics and clinically distinct HRS phenotypes with different outcomes.

1332 PREVALENCE AND OUTCOMES OF FRAILTY IN OLDER PEOPLE WITH UNPLANNED HOSPITAL ADMISSIONS: SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Background Guidelines recommend screening for frailty in all hospitalised older adults to inform care, based mainly on studies in outpatient and speciality-specific settings. However, most hospital bed-days in older people are for acute, non-elective admissions to general medicine, for which the prevalence and prognostic value of frailty might differ. Therefore, we undertook a systematic review of frailty prevalence and outcomes in older people with unplanned hospital admissions. Methods We searched MEDLINE, EMBASE and CINAHL up to 30/04/2021 for observational studies using validated frailty measures in unplanned adult hospital-wide or general medicine admissions. We related frailty prevalence to measurement tool, setting and risk of bias (RoB). Relative risks (RR) for mortality, length of stay (LOS), discharge destination and readmission were pooled using random-effects models where appropriate, and area-under-the-ROC-curves calculated. Heterogeneity was explored with meta-regression. Dose-response effects were assessed with the Cochran-Armitage test. Results Among 38 cohorts (median/SD age=80/5 years; n=37,733,147 admissions), the median prevalence of moderate-severe frailty was 40.5% (IQR=33.2-53.2; low-moderate RoB=23/38), with considerable heterogeneity (PQ&amp;lt;0.001) apparently unrelated to measure, setting or RoB. Nevertheless, frailty still predicted mortality (RR range=1.08-16.06), long LOS (range=1.35-3.04) and discharge destination (range=1.97-3.45) in all studies with more severe frailty associated with worse outcomes, although associations with 30-day readmission were conflicting (range=0.52-1.64). Studies reporting lower frailty prevalence showed stronger associations between frailty and mortality (beta=-0.009, P=0.03, R=49.6%), with the most consistent (PQ=0.11) associations found in studies using prospective measures (pooled RR=2.57, 95%CI=2.30-2.88) and little attenuation after adjustment for age, sex and comorbidity. Ordinal cut-points appeared to provide superior discrimination to dichotomous thresholds. Conclusions Frailty is common in older patients with acute, non-elective hospital admissions and remains an independent predictor of mortality, LOS and discharge home in the acute setting, justifying more widespread implementation of screening using prospective tools and consideration of the degree of frailty in guidance.

Etiologies and Predictors of 30-Day Readmission in Heart Failure: An Updated Analysis.

Readmissions in heart failure (HF), historically reported as 20%, contribute to significant patient morbidity and high financial cost to the healthcare system. The changing population landscape and risk factor dynamics mandate periodic epidemiologic reassessment of HF readmissions. National Readmission Database (NRD, 2019) was used to identify HF-related hospitalizations and evaluated for demographic, admission characteristics, and comorbidity differences between patients readmitted vs. those not readmitted at 30-days. Causes of readmission and predictors of all-cause, HF-specific, and non-HF-related readmissions were analyzed. Of 48,971 HF patients, the readmitted cohort was younger (mean 67.4 vs. 68.9 years, p≤0.001), had higher proportion of males (56.3% vs. 53.7%), lowest income quartiles (33.3% vs. 28.9%), Charlson comorbidity index (CCI) ≥3 (61.7% vs. 52.8%), resource utilization including large bed-size hospitalizations, Medicaid enrollees, mean length of stay (6.2 vs. 5.4 days), and disposition to other facilities (23.9% vs. 20%) than non-readmitted. Readmission (30-day) rate was 21.2% (10,370) with cardiovascular causes in 50.3% (HF being the most common: 39%), and non-cardiac in 49.7%. Independent predictors for readmission were male sex, lower socioeconomic status, nonelective admissions, atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, anemia, and CCI ≥3. HF-specific readmissions were significantly associated with prior coronary artery disease and Medicaid enrollment. Our analysis revealed cardiac and noncardiac causes of readmission were equally common for 30-day readmissions in HF patients with HF itself being the most common etiology highlighting the importance of addressing the comorbidities, both cardiac and non-cardiac, to mitigate the risk of readmission.