Nonsurgical Admissions Research Articles

Potentially preventable hospitalizations—The ‘pre‐hospital syndrome’: Retrospective observations from the MonashWatch self‐reported health journey study in Victoria, Australia

Rationale, Aims, and ObjectivesHealthLinks: Chronic Care is a state‐wide public hospital initiative designed to improve care for cohorts at‐risk of potentially preventable hospitalizations at no extra cost. MonashWatch (MW) is an hospital outreach service designed to optimize admissions in an at‐risk cohort. Telehealth operators make regular phone calls (≥weekly) using the Patient Journey Record System (PaJR). PaJR generates flags based on patient self‐report, alerting to a risk of admission or emergency department attendance. ‘Total flags’ of global health represent concerns about self‐reported general health, medication, and wellness. ‘Red flags’ represent significant disease/symptoms concerns, likely to lead to hospitalization.MethodsA time series analysis of PaJR phone calls to MW patients with ≥1 acute non‐surgical admissions in a 20‐day time window (10 days pre‐admission and 10 days post‐discharge) between 23 December 2016 and 11 October 2017. Pettitt's hypothesis‐testing homogeneity measure was deployed to analyse Victorian Admitted Episode/Emergency Minimum Datasets and PaJR data.FindingsA MW cohort of 103 patients (mean age 74 ± 15 years; with 59% males) had 263 admissions was identified. Bed days ranged from <1 to 37.3 (mean 5.8 ± 5.8; median 4.1). The MW cohort had 7.6 calls on average in the 20‐day pre‐ and post‐hospital period. Most patients reported significantly increased flags ‘pre‐hospital’ admission: medication issues increased on day 7.0 to 8.5; total flags day 3, worse general health days 2.5 to 1.8; and red flags of disease symptoms increased on day 1. These flags persisted following discharge.Discussion/ConclusionThis study identified a ‘pre‐hospital syndrome’ similar to a post‐hospital phase aka the well‐documented ‘post‐hospital syndrome’. There is evidence of a 10‐day ‘pre‐hospital’ window for interventions to possibly prevent or shorten an acute admission in this MW cohort. Further validation in a larger diverse sample is needed.

Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model.

The American College of Surgeons (ACS) mandates all trauma centers conduct individual case reviews of nonsurgical admissions when rates of allocation to this service exceed 10% of all inpatient traumas. Nonsurgical admission rates at the study institution, which is a Level I trauma center, historically exceeded this ACS criterion. In an effort to decrease nonsurgical admissions, the study institution recruited trauma nurse practitioners (TNPs) who began managing low acuity patients with oversight from trauma attending physicians. This study examines the impact of TNPs on the rate of nonsurgical admissions. A retrospective cohort study was conducted with 1,400 patients between January 2017 and October 2018. Two cohorts examined in this study included trauma patients whose care was managed by the TNPs versus those admitted under the care of hospitalists. The rate of admission to nonsurgical services (NSS) was 19.6% in 2017 and 13.9% in 2018, which yielded a significant decrease from previous years' percentages (p < .001). The average hospital length of stay was 1.17 days shorter in the TNP group, which translated into a savings of approximately $876,330 in hospital charges for the study period. Additional significant findings noted in favor of the TNP cohort were for discharge orders placed prior to noon, discharge location, and reduced time to the operating room. This TNP model proved to be successful in significantly reducing admissions to NSS and substantiated the quality of patient care provided by TNPs. Hospitals struggling to meet the ACS criterion for NSS admissions may consider implementing a similar TNP model.

Does the Halo Effect for Level 1 Trauma Centers Apply to High-Acuity Nonsurgical Admissions?

The halo effect describes the improved surgical outcomes at trauma centers for nontrauma conditions. To determine whether level 1 trauma centers have improved inpatient mortality for common but high-acuity nonsurgical diagnoses (eg, acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia [PNA]) compared with non--level 1 trauma centers. The authors conducted a population-based, retrospective cohort study analyzing data from the Healthcare Cost and Utilization Project State Inpatient Database and the American Hospital Association Annual Survey Database. Patients who were admitted with AMI, CHF, and PNA between 2006-2011 in Florida and California were included. Level 1 trauma centers were matched to non-level 1 trauma centers using propensity scoring. The primary outcome was risk-adjusted inpatient mortality for each diagnosis (AMI, CHF, or PNA). Of the 190,474 patients who were hospitalized for AMI, CHF, or PNA, 94,037 patients (49%) underwent treatment at level 1 trauma centers. The inpatient mortality rates at level 1 trauma centers vs non-level 1 trauma centers for patients with AMI was 8.10% vs 8.40%, respectively (P=.73); for patients with CHF, 2.26% vs 2.71% (P=.90); and for patients with PNA, 2.30% vs 2.70% (P=.25). Level 1 trauma center designation was not associated with improved mortality for high-acuity, nonsurgical medical conditions in this study.

Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model

Rate of Nonsurgical Admissions at a Level 1 Trauma Center: Impact of a Trauma Nurse Practitioner Model

Elderly Patients With Isolated Hip Fracture Requiring Surgical Intervention: Does Admitting Service Matter?

The American College of Surgeons requires trauma centers to track the number of injured patients admitted to a surgical service as well as nonsurgical admissions (NSAs) as a quality marker. We aim to compare the relationship between admitting service and outcomes in patients with isolated hip fracture (IHF). A 4-year retrospective cohort review of data collected from a single institution's trauma registry for adult patients with IHF was done. Patients were stratified into 2 groups based on admission to a surgical service versus NSA. Demographic and outcome variables including age, gender, Injury Severity Score (ISS), intensive care unit length of stay (ICU-LOS), deep venous thrombosis (DVT), and mortality rates were compared. Analysis of variance and χ test were used for data analysis with statistical significance defined as p < .05. A total of 629 patients with IHF were admitted. Of those, 30 (4.8%) were admitted to a surgical service and 599 (95.2%) were NSAs. Patients admitted to a surgical service were younger but average ISS was similar in both groups. Those admitted to a surgical service had a significantly shorter ICU-LOS than NSA patients (2.97 days vs. 4.91, p < .001). Readmission rate at 30 days (3.3% vs. 1.2%, p > .05) and DVT rates (0% vs. 0.4%, p > .05) were similar between groups. Mortality rates did not differ between groups (3.3% vs. 2.2%, p > .05). Patients with hip fracture requiring surgical intervention admitted to a trauma service have a shorter ICU-LOS than those admitted to nonsurgical services. Other quality markers were similar.

Frequency, Risk Factors, Causes, and Consequences of Diagnostic Errors in Critically Ill Medical Patients: A Retrospective Cohort Study.

Diagnostic errors are a source of significant morbidity and mortality but understudied in the critically ill. We sought to characterize the frequency, causes, consequences, and risk factors of diagnostic errors among unplanned ICU admissions. We conducted a retrospective cohort study of randomly selected nonsurgical ICU admissions between July 2015 and June 2016. Medical ICU at a tertiary academic medical center. Critically ill adults with unplanned admission to the medical ICU. The primary investigator reviewed patient records using a modified version of the Safer Dx instrument, a validated instrument for detecting diagnostic error. Two intensivists performed secondary reviews of possible errors, and reviewers met periodically to adjudicate errors by consensus. For each confirmed error, we judged harm on a 1-6 rating scale. We also collected detailed demographic and clinical data for each patient. We analyzed 256 unplanned ICU admissions and identified 18 diagnostic errors (7% of admissions). All errors were associated with harm, and only six errors (33%) were recognized by the ICU team within the first 24 hours. More women than men experienced a diagnostic error (11.7% vs 2.7%; p = 0.015, χ test). On multivariable logistic regression analysis, female sex remained independently associated with risk of diagnostic error both at admission (odds ratio, 5.18; 95% CI, 1.34-20.08) and at 24 hours (odds ratio, 11.6; 95% CI, 1.37-98.6). Similarly, Quick Sequential Organ Failure Assessment score greater than or equal to 2 at admission was independently associated with diagnostic error (odds ratio, 5.73; 95% CI, 1.72-19.01). Diagnostic errors may be an underappreciated source of ICU-related harm. Women and higher acuity patients appear to be at increased risk for such errors. Further research is merited to define the scope of error-associated harm and to clarify risk factors for diagnostic errors among the critically ill.

Patients with acute cholecystitis should be admitted to a surgical service.

In bowel obstruction and biliary pancreatitis, patients receive more expedient surgical care when admitted to surgical compared with medical services. This has not been studied in acute cholecystitis. Retrospective analysis of clinical and cost data from July 2013 to September 2015 for patients with cholecystitis who underwent laparoscopic cholecystectomy in a tertiary care inpatient hospital. One hundred ninety lower-risk (Charlson-Deyo) patients were included. We assessed admitting service, length of stay (LOS), time from admission to surgery, time from surgery to discharge, number of imaging studies, and total cost. Patients admitted to surgical (n = 106) versus medical (n = 84) service had shorter mean LOS (1.4 days vs. 2.6 days), shorter time from admission to surgery (0.4 days vs. 0.8 days), and shorter time from surgery to discharge (0.8 days vs. 1.1 days). Surgical service patients had fewer CT (38% vs. 56%) and magnetic resonance imaging (MRI) (5% vs. 16%) studies. Cholangiography (30% vs. 25%) and endoscopic retrograde cholangiopancreatography (ERCP) (3 vs. 8%) rates were similar. Surgical service patients had 39% lower median total costs (US $7787 vs. US $12572). Nonsurgical admissions of patients with cholecystitis are common, even among lower-risk patients. Routine admission to the surgical service should decrease LOS, resource utilization and costs. Therapeutic/care management, level IV.

Validation of the LACE readmission and mortality prediction model in a large surgical cohort: Comparison of performance at preoperative assessment and discharge time points

Study objectiveThe LACE index (Length of stay, admission Acuity, Charlson comorbidity index, and Emergency department visits within 6 months of current admission) is a practical tool designed to predict the risk of readmission or mortality within 30 days of hospital discharge. We sought to validate and examine its performance in a large surgical population at both the preoperative assessment and discharge time points. DesignRetrospective cohort study. SettingWe identified all admissions with a surgery or procedure at Vanderbilt University Medical Center (VUMC) between 2010 and 2015. PatientsA total of 192,670 admissions (age ≥ 18) were included in the study. InterventionsNone. MeasurementsLACE scores were calculated and analyzed with multivariable logistic regression. Discrimination was assessed with the c-statistic, calibration was assessed with calibration plots, and overall performance evaluated with the Brier score. Four models were created: admissions with any surgery or procedure, surgical admissions using actual length of stay (ALOS), surgical admissions using estimated length of stay (ELOS) and non-surgical procedural admissions. Main results192,670 admissions were included. The all admissions model c-statistic was 0.77 with a Brier score of 0.13. Surgical admissions with ALOS and ELOS had a c-statistic of 0.80, 0.82 and a Brier score of 0.10, 0.08 respectively. Non-surgical procedural admissions had a c-statistic of 0.76 and a Brier score of 0.14. Calibration for all models was adequate. ConclusionsThe LACE model for surgical and procedural admissions had good discrimination and adequate calibration. Analysis of the model applied to surgical admissions using ELOS demonstrated slightly better overall performance than ALOS, suggesting that LACE could be utilized for readmission risk stratification at the time of preoperative assessment.Clinical Trial and Registry URL: Not applicable.

Decreased Pediatric Trauma Length of Stay and Improved Disposition With Implementation of Lewin's Change Model.

Although often cared for nonoperatively, trauma is a surgical disease managed by surgical services in a multidisciplinary manner. The American College of Surgeons Committee on Trauma (ACS COT) emphasizes this as part of the ACS COT verification process and expects nonsurgical service admission rate of less than 10%. In this project, we developed a collaborative care model captained by surgical services with medical service consultation to achieve this goal for optimal care of injured patients. The project was conducted at a freestanding pediatric trauma center undergoing verification as a Level 1 ACS COT pediatric trauma center. The trauma registry was utilized to obtain nonsurgical service admission rate from January 2011 to June 2015. Lewin's 3-Step Model was utilized to guide change. Adherence to the new ACS standards was continually tracked and fallouts were addressed on an individual basis. Overall compliance was reported routinely through trauma and hospital quality programs. Individual successes and accomplishments were recognized and reinforced. At the inception of the project, nonsurgical admission rate was 30%. Implementation of Lewin's 3-Step Model nonsurgical admission rate decreased to 3%, representing a reduction of 27%. In addition, a 21% reduction in hospital length of stay, 3.78-3 days, was demonstrated with no change in 30-day readmission rate. Lewin's change model facilitated culture change to achieve ACS COT standards and reduced nonsurgical admissions to less than 10%. Reduction in hospital length of stay supports an improvement in the efficiency of care when directed by the pediatric trauma surgery team.

The Austrian DRG-system: Insights from the first 2 decades

ISSUE: Austria was amongst the first European countries introducing a DRG-based hospital payment system in 1997. Initially, the groups were based on 476 diagnoses related groups for non-surgical admissions and 374 procedure related groups. The DRGs are granted for any case between a distinct range of the length of stay. *** DESCRIPTION OF THE PROBLEM: While intended to decrease average length of stay (ALOS) as well as hospitalisation rates, Austria only experienced decreasing ALOS in the first 10 years of the DRG-system from 8.3 days in 1997 to 6.8 days in 2007. Hospitalisation rates, however, continued to increase from 23 discharges per 100 inhabitants to 26.1 discharges in 2007 albeit initial high rates. Overall, concerns on the effectiveness of DRGs as an appropriate payment system increased amongst policy makers resulting in an evaluation ten years after its introduction. *** RESULTS: Even though the evaluation did not propose any immediate measures it increased the awareness of actively adapting the DRG system as well as capacity planning in order to provide the right incentives. In 2006, the regions were put in charge of detailed capacity planning at hospitals level making them accountable for structural health reforms. Day cases were increasingly incentivised in the DRG system and with the health reform 2013 thresholds were set up as minimum day case rates for various procedures. The 2013 reform brought also the development of a DRG system for ambulant services provided in hospital outpatient clinics. Overall, hospitalisation rates started to decrease from 2008 onwards from 26.3 discharges to 23 discharges in 2016 per 100 inhabitants. *** LESSONS: Although effective with regard to reducing ALOS DRG-based hospital payment systems do not necessarily promote lower hospitalisation rates. For the Austrian case with a high density of hospitals beds joint effort with regard to capacity planning and permanent adjustment of the DRG-system were necessary to reduce hospital admissions.

The Austrian DRG-system: Insights from the first 2 decades

ISSUE: Austria was amongst the first European countries introducing a DRG-based hospital payment system in 1997. Initially, the groups were based on 476 diagnoses related groups for non-surgical admissions and 374 procedure related groups. The DRGs are granted for any case between a distinct range of the length of stay. *** DESCRIPTION OF THE PROBLEM: While intended to decrease average length of stay (ALOS) as well as hospitalisation rates, Austria only experienced decreasing ALOS in the first 10 years of the DRG-system from 8.3 days in 1997 to 6.8 days in 2007. Hospitalisation rates, however, continued to increase from 23 discharges per 100 inhabitants to 26.1 discharges in 2007 albeit initial high rates. Overall, concerns on the effectiveness of DRGs as an appropriate payment system increased amongst policy makers resulting in an evaluation ten years after its introduction. *** RESULTS: Even though the evaluation did not propose any immediate measures it increased the awareness of actively adapting the DRG system as well as capacity planning in order to provide the right incentives. In 2006, the regions were put in charge of detailed capacity planning at hospitals level making them accountable for structural health reforms. Day cases were increasingly incentivised in the DRG system and with the health reform 2013 thresholds were set up as minimum day case rates for various procedures. The 2013 reform brought also the development of a DRG system for ambulant services provided in hospital outpatient clinics. Overall, hospitalisation rates started to decrease from 2008 onwards from 26.3 discharges to 23 discharges in 2016 per 100 inhabitants. *** LESSONS: Although effective with regard to reducing ALOS DRG-based hospital payment systems do not necessarily promote lower hospitalisation rates. For the Austrian case with a high density of hospitals beds joint effort with regard to capacity planning and permanent adjustment of the DRG-system were necessary to reduce hospital admissions.

Effect of Cognitive Status on the Receipt of Procedures Requiring Anesthesia and Critical Care Admissions in Older Adults

ObjectiveTo investigate whether older adults with mild cognitive impairment (MCI) or dementia have higher rates of procedures requiring general anesthesia or intensive care unit (ICU) admissions compared with cognitively normal (CN) patients. Patients and MethodsA population-based cohort, 70 to 89 years old at enrollment, underwent clinical and longitudinal neurocognitive testing to identify those with MCI and dementia. We analyzed the effects of cognitive status (CN, MCI, or dementia) at entry into the study from October 1, 2004, through December 31, 2014, on the risk of receiving procedures requiring surgical anesthesia and ICU admission. ResultsOf 2436 participants, 1977 (81%) were CN, 387 (16%) had MCI, and 72 (3%) had dementia. Cognitively impaired individuals were sicker. Compared with CN individuals, the likelihood of receiving a procedure requiring anesthesia was similar in participants with MCI (adjusted hazard ratio [aHR]=0.98; P=.78). Participants with dementia were less likely to receive these procedures (aHR=0.50; P=.02). Compared with CN participants, the likelihood of ICU admission for any indication was increased for those with MCI (aHR=1.24; P=.03) and dementia (aHR=1.59; P=.04). Admissions to the ICU after procedures were not different in patients with either MCI or dementia (aHR=0.96; P=.83 and aHR=1.01; P=.98, respectively). ConclusionPatients with MCI or dementia are not more likely to undergo surgery, and neither are they more likely to require ICU admission after procedures. An increased rate of nonsurgical ICU admissions requires vigilance to prevent deterioration of nonsurgical diseases that may lead to ICU admissions.

Resilience, health perceptions, (QOL), stressors, and hospital admissions-Observations from the real world of clinical care of unstable health journeys in Monash Watch (MW), Victoria, Australia.

Rationale, aims, and objectivesMonash Watch (MW) aims to reduce potentially preventable hospitalisations in a cohort above a risk “threshold” identified by Health Links Chronic Care (HLCC) algorithms using personal, diagnostic, and service data. MW conducted regular patient monitoring through outbound phone calls using the Patient Journey Record System (PaJR). PaJR alerts are intended to act as a self‐reported barometer of stressors, resilience, and health perceptions with more alerts per call indicating greater risk.Aims: To describe predictors of PaJR alerts (self‐reported from outbound phone calls) and predictors of acute admissions based upon a Theoretical Model for Static and Dynamic Indicators of Acute Admissions.MethodsParticipants: HLCC cohort with predicted 3+ admissions/year in MW service arm for >40 days; n = 244. Baseline measures—Clinical Frailty Index (CFI); Connor Davis Resilience (CD‐RISC): SF‐12v2 Health Survey scores Mental (MSC) and Physical (PSC) and ICECAP‐O. Dynamic measures: PaJR alerts/call in 10 869 MW records. Acute (non‐surgical) admissions from Victorian Admitted Episode database. Analysis: Logistic regression, correlations, and timeseries homogeneity metrics using XLSTAT.FindingsBaseline indicators were significantly correlated except SF‐12_MCS. SF12‐MSC, SF12‐PSC and ICECAP‐O best predicted PaJR alerts/call (ROC: 0.84). CFI best predicted acute admissions (ROC: 0.66), adding CD‐RISC, SF‐12_MCS, SF‐12_PCS and ICECAP‐O with two‐way interactions improved model (ROC: 0.70). PaJR alerts were higher ≤10 days preceding acute admissions and significantly correlated with admissions. Patterns in PaJR alerts in four case studies demonstrated dynamic variations signifying risk. Overall, all baseline indicators were explanatory supporting the theoretical model. Timing of PaJR alerts and acute admissions reflecting changing stressors, resilience, and health perceptions were not predicted from baseline indicators but provided a trigger for service interventions.ConclusionBoth static and dynamic indicators representing stressors, resilience, and health perceptions have the potential to inform threshold models of admission risk in ways that could be clinically useful.

Contemporary Demographic, Treatment, and Geographic Distribution Patterns for Disorders of Sex Development.

This study aimed to describe the demographic characteristics, hospital utilizations, patterns of inpatient surgical management, and the overall state/regional variation in surgery rate among patients with disorders of sex development (DSD). We analyzed the Nationwide Inpatient Sample from 2001 to 2012 for patients younger than 21 years. DSD-related diagnoses and procedures were identified via International Classification of Diseases, Ninth Revision (ICD-9) codes. We identified a total of 43,968 DSD-related admissions. Of these, 73.4% of the admissions were designated as female and 642 (1.9%) were inpatient surgical admissions. Among neonates, less than 1% underwent any type of genital surgery. Nonsurgical admissions were associated with longer length of stay and higher cost. There was no significant regional variation in the rate of DSD surgeries, but we observed higher concentrations of DSD surgeries in states associated with tertiary referral centers.

Improve safety in patients at risk for sleep apnea.

The clinical risks associated with sleep apnea have been documented for a number of years but continue to attract limited attention in the general hospital population. While risk assessment tools have been developed and protocols for management adopted on a relatively routine basis, there is a continued disconnect between identifying at risk, undiagnosed patients in nonsurgical admissions. This article outlines one community hospital's initiative to identify patients at risk for sleep apnea with implementation of safety protocols, patient education and a post-hospitalization referral system to improve the clinical outcome and safety of a population at risk.

Variation in Use of Pediatric Cardiology Subspecialty Care: A Total Population Study in California, 1983 to 2011

BackgroundAmerican Academy of Pediatrics guidelines emphasize regionalized systems of care for pediatric chronic illness. There remains a paucity of information on the status of regionalized systems of care for pediatric congenital heart disease (CHD). ObjectivesThis study evaluated variations in use of pediatric cardiology specialty care centers (PCSCC) for pediatric patients with CHD in California between 1983 and 2011. MethodsWe performed a retrospective, total population analysis of pediatric CHD patients using the California Office of Statewide Health Planning and Development unmasked database. PCSCCs were identified by California's Title V program. ResultsThere were 164,310 discharges meeting inclusion criterion. Discharges from PCSCCs grew from 58% to 88% between 1983 and 2011. Regionalized care was highest for surgical (96%) versus nonsurgical (71%) admissions. Admissions with a public payer increased from 42% (1983) to 61% (2011). Total bed days nearly doubled, and median length of stay increased from 2 to 3 days (nonspecialty care) and from 4 to 5 days (specialty care). There was a decrease in the pediatric CHD in-hospital death rate from 5.1 to 2.3 per 100,000 between 1983 and 2011, and a shift toward a larger percent of deaths occurring in the newborn period. ConclusionsCalifornia’s inpatient regionalized specialty care of pediatric CHD has increased substantially since 1983, especially for surgical CHD discharges. The death rate has decreased, the number of bed days has increased, and a large proportion of these discharges now have public payers. Health care reform efforts must consider these shifts while protecting advances in regionalization of pediatric CHD care.

Higher haemoglobin levels and dedicated trauma admission are associated with survival after severe traumatic brain injury

Background: Prevention of secondary brain injury is a key component of acute management of patients with severe traumatic brain injury (TBI). Haemoglobin concentration may have an impact on optimization of cerebral oxygenation. Patients with TBI may best be served by an organized trauma service. The objective is to determine if haemoglobin concentration or dedicated trauma admission has an impact on outcomes after severe TBI.Methods: This study retrospectively analysed consecutive patients with severe TBI admitted to a level-I trauma centre over 3 years. Patients <16 years-old and with length of stay (LOS) <24 hours were excluded. Data were collected on demographics; injury severity; LOS; admission service; survival to discharge; and haemoglobin levels from hospital days 1–7. Data were also collected on number of transfusions of packed red blood cells. The sample was stratified based on admission service and survival to discharge.Results: Of 147 patients (age = 54.1 ± 3.7 years), overall mortality rate was 15.4% (n = 23). Overall, non-survivors had lower daily and 7-day mean haemoglobin levels (10.7 ± 0.9 vs. 12.9 ± 0.4 g dL−1, p < 0.001). Non-surgical admissions had lower haemoglobin levels and a higher mortality rate (28.9% vs. 12.2%, p < 0.001) compared to dedicated trauma admissions.Conclusions: Among patients with severe TBI, higher haemoglobin levels and maintenance as a dedicated trauma admission are associated with higher survival to discharge.

The anatomic location of pancreatic cancer as a prognostic factor for inpatient complications.

247 Background: Patients with cancer in the head of the pancreas (HP) have a higher frequency of biliary stents, which are associated with complications requiring hospitalization. We hypothesized that hospitalized patients with cancers of the HP have a higher incidence of morbidity and mortality as compared to patients with cancer in the body (B) or tail (T). The primary aim of this study was to investigate whether anatomic location of pancreatic primary lesions is associated with complications and mortality in hospitalized patients. Methods: The Nationwide Inpatient Sample (NIS) database was queried to identify all non-surgical hospital admissions for patients with a diagnosis of pancreatic cancer (PC) for 2011. Based on ICD-9 diagnosis codes, patients were divided into three groups: H, B, and T. Patient demographics, comorbidities, medical complications, and hospitalization outcomes were compared among these 3 groups by univariate analysis. Two sample independent t-tests were used to compare all linear variables, and Chi-squared tests were used to compare categorical data. Results: In total, 4,910 patient admissions were analyzed, of which 3,590 had H, 519 B, and 801 T. No difference was observed in the mean age for all three cohorts (67-68 years). Length of hospitalization for each cohort averaged 6 days. Patient with pancreatic cancer of tail had statistically significant higher incidence of pneumonia (H 4.7%, B 6.2%, T 9.1%, p&lt;0.001), deep venous thrombosis (H 5.5%, B 10.6%, T 13.5%, p&lt;0.001), pulmonary embolic (H 3.3%, B 6.9%, T 9.4%, p&lt;0.001), cerebral vascular events (H 0.7%, B 1.5%, T 2.9%, p&lt; 0.001), ileus (H 6.0%, B 8.1%, T 10%, p&lt;0.001), encephalopathy (H 2.0%, B 1.7%, T 3.5%, p=0.02), acute renal failure (H 13%, B 9.1%, T 15%, p= 0.005), and in-hospital mortality (H 5.3%, B 6.9%, T 8.9%, p&lt;0.001). Conclusions: In this study, pancreatic cancer of the tail correlates with higher incidences of in-hospital complications and mortality. This suggest that the impact of biliary stents on outcome of hospitalized patients with PC may be limited. Anatomic location of pancreatic malignancy may also be utilized as prognostic factor in management of inpatient PC patients.

Prognostic value of gender in hospitalized pancreatic patients.

256 Background: Women with pancreatic cancer (PC) are known to have a longer overall survival compared with men. However, no data address the association of gender with acute medical complications in the inpatient setting. We hypothesize that women with PC have fewer inpatient medical complications than men. Methods: The Nationwide Inpatient Sample (NIS) database was queried to identify all non-surgical hospital admissions for patients with a diagnosis of pancreatic cancer for 2011. We compared inpatient complications and mortality between females and males with PC using univariate and multivariate logistic regression model. Two sample independent t-tests were used to compare all linear variables, and Chi-squared tests were used to compare categorical data. Results: Of the 16,616 PC patients analyzed, there were 8,324 females (F) and 8,292 males (M). Mean age was 69 (F) and 67 (M). Length of stay for both averaged 6 days. After adjusting for gender, age, race, inpatient chemotherapy, and comorbidities (depression, alcoholism, arthritis, coagulopathies, drug use, diabetes, hypertension, hypothyroidism, liver disease [dz], metastatic dz, obesity, perivascular dz, renal failure), multivariate analysis showed that male gender in PC patients is independently associated with increased incidence of pneumonia (p&lt;0.001, RR 0.77), pulmonary embolism (p=0.006, RR 0.80), ileus (p=0.001, RR 0.79), and acute renal failure (p&lt;0.001, RR 0.76). Female patients experienced higher incidence of urinary tract infection (p&lt;0.001, RR 1.9). Although incidence of mortality for male patients with PC was higher by univariate analysis (p= 0.005), it was not significantly higher by multivariate analysis (p= 0.087). Conclusions: In this study, men admitted with PC suffer higher incidences of inpatient complications compared to women. These findings may partly explain the higher overall survival rate of women compared to men with PC. It also implicates gender as prognostic tool in the management of hospitalized PC patients.

Volume-Outcome Relationships for Mechanically Ventilated Adult Patients

For mechanically ventilated patients there is a significant relationship between the annual volume (absolute number) of mechanically ventilated admissions to UK intensive care units and acute hospital mortality. Intensive care units admitting more than 321 ventilated patients per annum demonstrated a statistically significant survival benefit (p&lt;0.02). This relationship was most pronounced among non-surgical admissions. Level of evidence: Level 2B: retrospective cohort study, but with concerns over validity.