In-hospital Mortality Odds Ratio Research Articles

Is there excessive troponin testing in clinical practice? Evidence from emergency medical admissions

Aim: To investigate whether excessive high-sensitivity cardiac troponin T (hscTnT) testing, in non-cardiac presentations, increases hospital length of stay (LOS) by driving down-stream investigations. Methods: We report on all hscTnT tests in emergency medical admissions, performed over a 9-year period between 2011-2019. Troponin testing frequency in different risk cohorts was determined and related to 30-day in-hospital mortality with a multivariable logistic regression model adjusted for other outcome predictors. Downstream utilization of procedures/services was related to LOS with zero truncated Poisson regression. Results: There were 66,475 admissions in 36,518 patients. hscTnT was tested in 24.4% of admissions, more frequently in the elderly (>70 years 33.4%, >80 years 35.9%), cardiovascular presentations (33.6%) and in those with high comorbidity (42.2%), and reduced in those with neurologic presentations (20%). A hscTnT request predicted increased 30-day in-hospital mortality OR 3.33 (95% CI: 3.06, 3.64). The univariate odds ratio (OR) of hscTnT test result was 1.45 (95% CI: 1.42, 1.49) and was semi-quantative with worsening outcomes as hscTnT increased. It remained predictive in the fully adjusted model OR 1.17 (95% CI: 1.09, 1.26). LOS was linearly related to the number of procedures/services performed. hscTnT testing did not increase LOS or number of procedures/services Conclusion: A clinical request for hscTnT testing is prognostic and risk categorises. Subsequent resource utilization, if increased, appears an epiphenomenon related to risk categorisation, rather than being driven by inappropriate hscTnT testing.

The effect of bed-to-nurse ratio on hospital mortality of critically ill children on mechanical ventilation: a nationwide population-based study

BackgroundDespite the high workload of mechanical ventilation, there has been a lack of studies on the association between nurse workforce and mortality in mechanically ventilated patients. We evaluated the association of the bed-to-nurse ratio with mortality in ventilated pediatric patients admitted to an intensive care unit (ICU).MethodsWe conducted a nationwide retrospective analysis by using the Korean National Health Insurance database, which categorizes the bed-to-nurse ratio into 9 grades according to the number of beds divided by the number of full-time equivalent registered nurses in a unit. Patients of ages between 28 days and 18 years were enrolled. Multiple admissions and transfers from other hospitals were excluded. We evaluated the odds ratios (ORs) of in-hospital mortality using 4 groups (Grade 1: bed-to-nurse < 0.50, Grade 2: < 0.63, Grade 3: < 0.77, Grade 4 or above > 0.77) with adjustment of patient factors, hospital factors, and treatment requirements.ResultsOf the 27,849 patients admitted to ICU, 11,628 (41.8%) were on mechanical ventilation. The overall in-hospital mortality rates in Grade 1, Grade 2, Grade 3, and Grade 4 or above group were 4.5%, 6.8%, 6.9%, and 4.7%, respectively. The adjusted ORs (95% CI) for in-hospital mortality of mechanically ventilated patients in the Grade 2, Grade 3, and Grade 4 or above compared to those in Grade 1 were 2.73 (95% CI 1.51–4.95), 4.02 (95% CI 2.23–7.26), and 7.83 (4.07–15.07), respectively. However, for patients without mechanical ventilation, the adjusted ORs of in-hospital mortality were not statistically significant.ConclusionIn mechanically ventilated patients, the adjusted mortality rate increased significantly, as the bed-to-nurse ratio of the ICU increased. Policies that limit the number of ventilated patients per nurse should be considered.Trial registration retrospectively registered

CHA2DS2-VASc Is Associated With In-Hospital Mortality in Patients With Infective Endocarditis: A Cross-Sectional Cohort Study.

Background and objectiveThe CHA2DS2-VASc score is a stroke risk stratification tool that is used in patients with atrial fibrillation (AF). Most of its clinical variables have been associated with poor outcomes in patients with infective endocarditis (IE). In this study, we aimed to determine its utility in predicting outcomes in IE patients.MethodsWe included 35,570 patients with IE from the National Inpatient Sample (NIS), 2009-2012. The CHA2DS2-VASc score was calculated for each patient. Hierarchical logistic regression was used to estimate the adjusted odds ratio for in-hospital mortality for CHA2DS2-VASc scores from 1 to 9, using a score of 0 as the reference score. All clinical characteristics were defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.ResultsThe mean age of the sample was 57.81 ±14 years. Higher CHA2DS2-VASc scores were associated with increased mortality, and the scores among the sample ranged from 0 for 8.1% to 8 for 21.7%. In the hierarchical logistic regression, after adjusting for age, sex, and relevant comorbidities, as the score increased, so did the odds for overall mortality.ConclusionIn patients with IE, the CHA2DS2-VASc score may serve as a risk assessment tool with which to predict outcomes. Further studies are needed to replicate these findings.

Impact of serum phosphate changes on in-hospital mortality

BackgroundFluctuations in serum phosphate levels increased mortality in end-stage renal disease patients. However, the impacts of serum phosphate changes in hospitalized patients remain unclear. This study aimed to test the hypothesis that serum phosphate changes during hospitalization were associated with in-hospital mortality.MethodsWe included all adult hospitalized patients from January 2009 to December 2013 that had at least two serum phosphate measurements during their hospitalization. We categorized in-hospital serum phosphate changes, defined as the absolute difference between the maximum and minimum serum phosphate, into 5 groups: 0–0.6, 0.7–1.3, 1.4–2.0, 2.1–2.7, ≥2.8 mg/dL. Using serum phosphate change group of 0–0.6 mg/dL as the reference group, the adjusted odds ratio of in-hospital mortality for various serum phosphate change groups was obtained by multivariable logistic regression analysis.ResultsA total of 28,149 patients were studied. The in-hospital mortality in patients with serum phosphate changes of 0–0.6, 0.7–1.3, 1.4–2.0, 2.1–2.7, ≥2.8 mg/dL was 1.5, 2.0, 3.1, 4.4, and 10.7%, respectively (p < 0.001). When adjusted for confounding factors, larger serum phosphate changes were associated with progressively increased in-hospital mortality with odds ratios of 1.35 (95% 1.04–1.74) in 0.7–1.3 mg/dL, 1.98 (95% CI 1.53–2.55) in 1.4–2.0 mg/dL, 2.68 (95% CI 2.07–3.48) in 2.1–2.7 mg/dL, and 5.04 (95% CI 3.94–6.45) in ≥2.8 mg/dL compared to serum phosphate change group of 0–0.6 mg/dL. A similar result was noted when we further adjusted for either the admission or mean serum phosphate during hospitalization.ConclusionGreater serum phosphate changes were progressively associated with increased in-hospital mortality.

S1151 In-Hospital Outcomes of Patients With Pulmonary Hypertension and Cirrhosis: A Six-Year Population Cohort Study of Over One Million Patients

INTRODUCTION: There is a scarcity of data regarding the influence of sex, race, insurance, and PH-related and cirrhosis-related complications on mortality, hospital length of stay (LOS), and total hospitalization charges. In this study, we aim to identify risk factors in a national population cohort admitted from 2012 to 2017. METHODS: All patients >18 years old with pulmonary hypertension (PH) and cirrhosis admitted were identified from the Nationwide Inpatient Sample (NIS). Multivariate Regression analysis was used to estimate the odds ratio of in-hospital mortality, average length of stay and hospital charges, after adjusting for age, gender, race, primary insurance payer, hospital type, hospital bed size, hospital region, hospital teaching status, mortality rate, length of stay, associated charges, and demographic characteristics. RESULTS: Overall sample included 1,111,594 patients. 355,455 patients were admitted with PH, of which 3% were complicated with cirrhosis (n = 34,986). Patients with PH and cirrhosis compared to patients with only PH have increased mortality, hospital LOS, total hospital charges, and PH-related and cirrhosis-related complications. Independent positive predictors of mortality were Asian/Pacific Islander race, other insurance status. Independent positive predictors of increased hospital LOS were black race, other patients. Independent positive predictors of increased total charges were male gender, Hispanic ethnicity, Asian/Pacific Islander race, other insurance status; independent negative predictors were Medicaid insurance, self-pay for insurance, and no charge insurance. PH-related [cor pulmonale, PE, hemoptysis, cardiac arrest, atrial fibrillation, ventricular tachycardia] and cirrhosis-related complications [ascites, hepatorenal syndrome, hepatic encephalopathy (HE), variceal bleeding, portal hypertension] were independent positive predictors of: mortality, hospital LOS, and total hospital charges. CONCLUSION: PH and cirrhosis lead to increased mortality and hospital utilization compared to patients with only PH. We identified key drivers for these outcomes. Targeted interventions are needed for the subgroups identified in this study. PH and cirrhosis can often coexist due to complex pulmonary-hepatic interactions, but these patients are very ill and at high-risk for complications. In the future, it is critical to better understand the complex pathophysiological relationship between these two diseases with randomized controlled trials and further studies.

In-hospital Outcomes of Patients With Acute Decompensated Heart Failure And Cirrhosis An Analysis of The National Inpatient Sample

Introduction Heart failure theoretically increases morbidity and mortality in patients admitted for cirrhosis. However, there is a paucity of data regarding the influence of sex, race, insurance, and cirrhosis related complications on mortality, length of stay, and total hospitalization charges. In this study we aim to identify risk factors in a national population cohort admitted in 2016. Methods All patients >18 years old with Cirrhosis and acute decompensated heart failure (ADHF) admitted in 2016 were identified from the Nationwide Inpatient Sample. Multivariate Regression analysis was used to estimate the odds ratio of in-hospital mortality, average length of stay and hospital charges, after adjusting for age, gender, race, Charlson and Elixhauser score, primary insurance payer, hospital type, hospital bed size, hospital region, hospital teaching status, mortality rate, length of stay, associated charges, and demographic characteristics. Statistical analysis was performed by using SAS Survey Procedures (SAS 9.4, SAS Institute Inc, Cary, NC, USA). Statistical significance was defined by the two-sided test with a p-value Results Overall sample included 363,050 patients. 355,455 patients were admitted with ADHF, of which 2% were complicated with cirrhosis (n=7,595) in 2016. Total Mortality rate was 3.4%, length of stay 6.6 days (6.5) and mean total hospital charge was $63,120.2.Patients with ADHF and cirrhosis compared to patients without ADHF have increased mortality, length of stay, and cirrhosis related complications. Independent predictors of mortality were hepatorenal syndrome (HRS), ascites, and hepatic encephalopathy (HE). Hispanic race and Medicare were negative predictors, associated with worse outcomes. Length of stay was increased if patients had Medicare, HRS, and ascites. Predictors of total hospital charge were Hispanic ethnicity, Asian/pacific islander race, HRS, ascites and HE. Conclusions ADHF in patients with cirrhosis leads to increased mortality and hospital utilization. We identified key drivers for these outcomes. Targeted interventions are needed for the subgroups identified in this study.

The role of Frailty on Adverse Outcomes Among Older Patients with COVID-19

BackgroundDiagnosis and screening of frailty, a condition characterized by an increased vulnerability to adverse outcomes of COVID-19, has emerged as an essential clinical tool which is strongly recommended by healthcare providers concerned with hospitalized elderly population. The data showing the role of frailty in patients infected with COVID-19 is needed. MethodsThis was a nationwide cohort study conducted at all hospitals in Turkey. All COVID-19 hospitalized patients (≥ 65 years) were included. Patients who were alive and not discharged up to July 20, 2020, were excluded. The frailty was assessed by using the “Hospital Frailty Risk Score” (HFRS). Patients were classified into three risk groups of frailty based on previously validated cut points as low (<5 points), intermediate (5-15 points), and high (>15 points). Additionally, patients who had the HFRS of ≥5 were defined as frail. The primary outcome was in-hospital mortality rates by frailty group. ResultsBetween March 11, 2020, and June 22, 2020, a total of 18,234 COVID-19 patients from all of 81 provinces of Turkey were included. Totally, 12,295 (67.4%) patients were defined as frail (HFRS of >5) of which 2,801 (15.4%) patients were categorized in the highest level of frailty (HFRS of >15). Observed in-hospital mortality rates were 697 (12.0%), 1,751 (18.2%) and 867 (31.0%) in low, intermediate and high hospital frailty risk, respectively (p<0.001). Compared with low HFRS (<5), the adjusted odds ratios for in-hospital mortality were 1.482 (1.334-1.646) for intermediate HFRS (5-15) and 2.084; 95% CI, 1.799-2.413 for high HFRS (>15). ConclusionsAs a claims-based frailty model, the HFRS provides clinicians and health systems, a standardized tool for an effective detection and grading of frailty in patients in COVID-19. A frailty-based tailored management of the older population may provide a more accurate risk categorization for both therapeutic and preventive strategies.

Body temperature and in-hospital mortality in trauma patients: analysis of a nationwide trauma database in Japan.

Avoiding body temperature (BT) abnormalities has been emphasized in trauma care, and BT correction in the initial treatment period may improve patient outcome. However, the effect of hyperthermia at hospital arrival on mortality in trauma patients is unclear. This study aimed to identify the association between BT and in-hospital mortality among adult trauma patients. This was a retrospective analysis of a multi-centre prospective cohort study. Data were obtained from the Japan Trauma Data Bank (JTDB). Adult trauma patients who were transferred directly from the scene of injury to the hospital and registered in the JTDB between January 2004 and December 2017 were included. The primary outcome was the association between BT at hospital arrival and in-hospital mortality. BT at hospital arrival was classified by 1°C strata. We conducted multivariable logistic regression analyses to calculate the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality for each BT group using 36.0-36.9°C as a reference. Overall, 153,117 patients were included. The total mortality rate was 7% (n = 10,118). The adjusted OR for in-hospital mortality for < 35.0°C was 1.65 (95% CI 1.51-1.79, p < 0.001), 35.0-35.9°C was 1.33 (95% CI 1.25-1.41, p < 0.001), 37.0-37.9°C was 0.99 (95% CI 0.91-1.07, p = 0.639), 38.0-38.9°C was 1.30 (95% CI 1.08-1.56, p = 0.007) and > 39.0°C was 1.62 (95% CI 1.18-2.22, p = 0.003) compared to that for normothermia. Our results reveal that hypothermia and hyperthermia at hospital arrival are associated with increased in-hospital mortality in adult trauma patients.

In-Hospital Outcomes of Patients With Pulmonary Hypertension and Cirrhosis: A 6-Year Population Cohort Study of Over One Million Patients.

IntroductionThere is a paucity of data on the influence of sex, race, insurance, pulmonary hypertension-related complications, and cirrhosis-related complications on mortality, hospital length of stay (LOS), and total hospital charges. The aim of this study was to identify risk factors in a national population cohort (in the USA) admitted to hospital between 2012 and 2017.MethodsAll patients aged > 18 years with pulmonary hypertension and cirrhosis, who had been admitted to hospital between 2012 and 2017, were identified from the US Nationwide Inpatient Sample (NIS), a large publicly available all-payer inpatient care database in the USA. Multivariate regression analysis was used to estimate the odds ratios of in-hospital mortality, average length of hospital stay, and hospital charges, after adjusting for age, gender, race, primary insurance payer status, hospital type and size (number of beds), hospital region, hospital teaching status, and other demographic characteristics.ResultsOur study identified 1,111,594 patients who had been discharged from hospital from 2012 to 2017. Of these patients, 355,455 were admitted with pulmonary hypertension, with 9.8% having cirrhosis as a complication (n = 34,986). The analysis revealed that patients with both pulmonary hypertension and cirrhosis compared to patients with only pulmonary hypertension experience increased mortality, hospital LOS, total hospital charges, and pulmonary hypertension-related and cirrhosis-related complications. Independent positive predictors of mortality were Asian/Pacific Islander race and "other" insurance status (worker’s compensation; other US health benefits plans [CHAMPUS/TRICARE, CHAMPVA, Title V]). Independent positive predictors of increased hospital LOS were black race and "other" patients (more than one race/mixed). Independent positive predictors of increased total hospital charges were male gender, Hispanic ethnicity, Asian/Pacific Islander race, and other insurance status. Pulmonary hypertension-related complications (cor pulmonale, pulmonary embolism, hemoptysis, cardiac arrest, atrial fibrillation, ventricular tachycardia) and cirrhosis-related complications (ascites, hepatorenal syndrome, hepatic encephalopathy, variceal bleeding, portal hypertension) were independent positive predictors of mortality, hospital LOS, and total hospital charges.ConclusionsPatients with pulmonary hypertension and cirrhosis have increased mortality and hospital utilization compared to patients with only pulmonary hypertension. We identified key drivers for these outcomes. Targeted interventions, such as novel medications, right-to-left shunts, more evaluations for lung transplantation, and reversal of pulmonary vacular remodeling, are needed for the subgroups identified in this study in order to improve outcomes.

Association of weekend admission and clinical outcomes in hospitalized patients with sepsis: An observational study.

Sepsis is associated with impaired clinical outcomes. It requires timely diagnosis and urgent therapeutic management. Because staffing during after-hours is limited, we explored whether after-hour admissions are associated with worse clinical outcomes in patients with sepsis.In this retrospective cohort study, we analyzed nationwide acute care admissions for a main diagnosis of sepsis in Switzerland between 2006 and 2016 using prospective administrative data. The primary outcome was in-hospital mortality using multivariable logistic regression models. Secondary outcomes were intensive care unit (ICU) admission, intubation, and 30-day readmission.We included 86,597 hospitalizations for sepsis, 60.1% admitted during routine-hours, 16.8% on weekends and 23.1% during night shift. Compared to routine-hours, we found a higher odds ratio (OR) for in-hospital mortality in patients admitted on weekends (Adjusted OR 1.05, 95% confidence interval [95% CI] 1.01, 1.10, P = .041). Also, the OR for ICU admission (OR 1.14, 95% CI 1.10, 1.19, P < .001) and intubation (OR 1.18, 95% CI 1.12, 1.25 P < .001) was higher for weekends compared to routine-hours. Regarding 30-day readmission, evidence for an association could not be observed. Night shift admission, compared to routine-hours, was associated with a higher OR for ICU admission and intubation (ICU admission: OR 1.28 (1.23, 1.32), P < .001; intubation: OR 1.31, 95% CI 1.25, 1.37, P < .001) but with a lower OR for in-hospital mortality (OR 0.93, 19% CI 0.89, 0.97, P = .001).Among hospitalizations with a main diagnosis of sepsis, weekend admissions were associated with higher OR for in-hospital mortality, ICU admission, and intubation. Whether these findings can be explained by staffing-level differences needs to be addressed.

Frailty Index Is a Poor Predictor of Postoperative Morbidity and Mortality After Ruptured Abdominal Aortic Aneurysm

Abstract Objectives : Frailty has gained prominence as a predictor of postoperative outcomes across a number of surgical specialties, vascular surgery included. The role of frailty is less defined in the acute surgical setting. We assessed the prognostic value of frailty for patients undergoing surgery for a ruptured abdominal aortic aneurysm (rAAA). Methods : A single-institution retrospective chart review of all patients undergoing surgical intervention for rAAA between January 1, 2011 and November 27, 2019 was performed. Frailty was assessed for each patient using the modified frailty index (mFI), a validated frailty metric based on the Canadian Study of Health and Aging. Frailty was defined as an mFI ≥ 0.27. The performance of the mFI was compared to that of the Vascular Study Group of New England (VSGNE) rAAA mortality risk score. Chi square, Fisher's exact, and t tests, were used to evaluate for associations between frailty and in-hospital outcomes. Univariate and multivariate logistic regression were used to obtain odds ratios for in-hospital mortality. A receiver operating characteristic (ROC) curve was generated to compare the predictive value of the mFI and VSGNE score for in-hospital mortality. Results : Sixty patients were identified during the study period with an in-hospital mortality rate of 37%. Twenty-one patients were deemed frail by mFI metric and included all patients with known myocardial infarction, stroke with a neurologic deficit or dependent functional status, however the mortality rate did not differ significantly based on frailty status (33% non-frail vs. 43% frail, p=0.47). Frailty status was not significantly different for patients with acute kidney injury (10% non-frail vs. 10% frail), prolonged intubation (13% vs. 5%), abdominal compartment syndrome (8% vs. 10%), and Type I or Type III endoleak (8% vs. 19%). On multivariate analysis controlling for systolic blood pressure 2.0 mg/dl, the mFI produced an adjusted odds ratio (aOR) of 0.7 (95% confidence interval [CI]: 0.2-3.0). The ROC curve for the mFI produced an area under the curve (AUC) of 0.55 (p=0.55) for in-hospital mortality while that of the VSGNE score produced an AUC of 0.69 (p=0.02). Conclusions : The mFI did not significantly predict in-hospital outcomes after rAAA in this cohort. This suggests that the baseline health status of a patient with rAAA may play a less significant role in their postoperative prognosis than their acuity on presentation. Funding : This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

In-Hospital Outcomes of Patients with Acute Decompensated Heart Failure and Cirrhosis: An Analysis of the National Inpatient Sample.

IntroductionHeart failure increases morbidity and mortality in patients admitted for cirrhosis. Our objective was to determine if patients with acute decompensated heart failure (ADHF) and cirrhosis would have increased mortality, hospital length of stay (LOS), and total hospital charges compared to patients with only ADHF. There is also a paucity of data regarding the influence of gender, race, ethnicity, insurance, and cirrhosis-related complications on mortality, hospital length of stay, and total hospitalization charges. In this study, we aim to identify risk factors in a national population cohort from 2016.MethodsAll patients above 18 years old with cirrhosis and ADHF admitted in 2016 were identified from the Nationwide Inpatient Sample (NIS). Multivariate regression analysis was used to estimate the odds ratio of in-hospital mortality, average length of stay (LOS), and total hospital charges after adjusting for the following factors: age, gender, race, Charlson and Elixhauser scores, primary insurance payer status, hospital type, hospital bed size, hospital region, and hospital teaching status. Statistical analysis was performed by using the survey procedures function in the statistical analysis system (SAS) software. Statistical significance was defined by the two-sided t-test with a p value < 0.05.ResultsThe overall sample contained 363,050 patients. A total of 355,455 patients were admitted with ADHF and 2% of these patients had concomitant cirrhosis (n = 7595) in 2016. The total mortality rate was 3.4%, hospital LOS was 6.6 days (with a median of 6.5 days), and the mean total hospital charge was $63,120.20. Patients with both ADHF and cirrhosis compared to patients without ADHF had increased mortality, hospital LOS, and cirrhosis-related complications.ConclusionsAs the incidence and prevalence of ADHF and cirrhosis increases worldwide, we urge the medical community to increase surveillance of patients with both diseases and perform rigorous cardiovascular risk assessments as well to improve patient outcomes.

A Cross-Sectional Study of GLIM-Defined Malnutrition Based on New Validated Calf Circumference Cut-off Values and Different Screening Tools in Hospitalised Patients over 70 Years Old.

The Global Leadership Initiative on Malnutrition (GLIM) is new criteria for diagnosing malnutrition that need validation adjusted to race. Our aim is to determine the optimal reference values of calf circumference (CC), investigate the prevalence of GLIM-defined malnutrition based on different screening tools in inpatients over 70 years old in China and assess its relationship with clinical outcomes. We designed two continuity studies by analyzing a prospective multicenter database. First, we estimated and validated the CC cut-off values by receiver operating characteristic analyses against in-hospital mortality. Then the patients who were at risk by NRS 2002, MNA-SF and MUST were assessed by the GLIM criteria using the new CC values. Some clinical parameters and outcome data were evaluated. The optimal cut-off values of CC were 29.6 cm for male patients and 27.5 cm for female patients. The prevalence of GLIM-defined malnutrition was 27.5% by using NRS2002, 32.6% by using MNA-SF and 25.4% by using MUST. Patients with GLIM-defined malnutrition showed significantly worse values in BMI, total protein, albumin, neutrophil/lymphocyte ratio, CC, rate of complication, in-hospital mortality, length of stay, and total hospital cost than normal patients. Multivariate logistic regression showed the odds ratio of in-hospital mortality was significantly associated with GLIM defined malnutrition by using MNA-SF [OR = 1.231, 95%CI (1.022, 1.484), P = 0.029]. The Chinese reference values of CC for inpatients over 70 years old were validated by in-hospital mortality, which could be implemented in GLIM criteria. And this population possessed a high prevalence of nutrition risk and malnutrition. GLIM criteria with MNA-SF seems to be the first choice to diagnose malnutrition.

Disparities in mortality after abdominal aortic aneurysm repair are linked to insurance status

ObjectiveThe objective of this study was to determine differences in mortality after abdominal aortic aneurysm (AAA) repair based on insurance type. MethodsIn this retrospective cohort study, data from all-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California from January 2007 to December 2014 (excluding California, ending December 2011) were extracted from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. There were 90,102 patients ≥18 years old with available insurance data who underwent open AAA repair or endovascular aneurysm repair (EVAR) identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 3844, 3925, and 3971. EVAR patients were identified using the procedure code 3971, and the remainder of cases were categorized as open. Patients were divided into cohorts by insurance type as Medicare, Medicaid, uninsured (self-pay/no charge), other, or private insurance. Patients were further stratified for subgroup analyses by procedure type. Unadjusted rates of in-hospital mortality, the primary outcome, as well as secondary outcomes, such as surgical urgency, 30-day and 90-day readmissions, length of stay, total charges, and postoperative complications, were examined by insurance type. Adjusted odds ratios (ORs) for in-hospital mortality were calculated using multivariate logistic regression models fitted to the data. The multivariate models included patient-, surgical-, and hospital-specific factors with bivariate baseline testing suggestive of association with insurance status in addition to variables that were selected a priori. ResultsMedicaid and uninsured patients had the highest rates of mortality relative to private insurance beneficiaries in all cohorts. Medicaid patients incurred a 47% increase in the odds of mortality, the highest among the insured, after all AAA repairs (OR, 1.47; 95% confidence interval [CI], 1.23-1.76), whereas uninsured patients experienced a 102% increase in the odds of mortality (OR, 2.02; 95% CI, 1.54-2.67). Subgroup analyses for open AAA repair and EVAR corroborated that Medicaid insurance (open repair OR, 1.37 [95% CI, 1.14-1.64]; EVAR OR, 2.06 [95% CI, 1.40-3.04]) and uninsured status (open repair OR, 1.85 [95% CI, 1.35-2.54]; EVAR OR, 2.96 [95% CI, 1.82-4.81]) were associated with the highest odds of mortality after both procedures separately. ConclusionsThis study demonstrates that Medicaid insurance and uninsured status are associated with higher unadjusted rates and adjusted ORs for in-hospital mortality after AAA repair relative to private insurance status. Primary payer status therefore serves as an independent predictor of the risk of death subsequent to AAA surgical interventions.

Do patients with non-ST-elevation myocardial infarction without chest pain suffer a poor prognosis?

ObjectivePrevious studies have discussed acute myocardial infarction (AMI) patients without chest pain, but have not focused on non-ST-elevation myocardial infarction (NSTEMI). Materials and methodsThis 1-year study investigated whether chest pain presence relates to demographics, risk factors, and outcomes in NSTEMI patients. We retrospectively reviewed 194 patients, 73 without chest pain vs. 121 with chest pain, and compared the differences between clinical presentations, risk factors, medical management, and outcomes of these two groups. ResultsCompared to patients with chest pain, patients without chest pain were significantly older, had lower SBP, higher HR, more cerebrovascular disease, less ischemic heart disease, higher delay to ED (emergency department) visit, lower ED medication prescriptions, lower percutaneous cardiac intervention, and higher in-hospital and one-year mortality rate. In a multivariate logistic regression, the adjusted odds ratios (OR) of patients without chest pain were 4.38 for the elderly, 0.99 for every 1 mmHg increase in SBP, 1.02 for every beat/min HR increase, 0.37 for those with ischemic heart disease, and 5.09 for those with cerebrovascular disease. The adjusted OR of in-hospital mortality were 3.09 for patients without chest pain, 0.32 for those with hypertension, 0.32 for smokers, 3.98 for those with shock, and 0.16 for those with percutaneous cardiac intervention. Finally, the only significantly adjusted OR of one-year mortality was 5.37 for patients without chest pain. ConclusionNSTEMI patients without chest pain were significantly older, had lower SBP, more tachycardia, more cerebrovascular disease, but less ischemic heart disease. They also experienced higher in-hospital and one-year mortality rates.

473. Impact of Adjunctive Clindamycin in Invasive β-Hemolytic Streptococcal Infections: A Propensity Score-matched Analysis of 1956 β-lactam Treated Patients from 118 US Hospitals

BackgroundClindamycin suppresses invasive β-hemolytic streptococcal (iBHS) toxin production and its cidality, unlike β-lactams, is independent of bacterial inoculum. Evidence favoring the use of adjunctive clindamycin in iBHS is predominantly from in vitro and animal studies. Clinical studies, limited to single-center series or active surveillance, have yielded mixed results. Furthermore, its role in infections caused by non–group A or B β-hemolytic streptococci (NABS) remains poorly defined. Previously we were unable to demonstrate a clindamycin survival benefit in patients with group A streptococci (GAS) bacteremia. Here we examined the impact of adjunctive clindamycin on survival among patients with either invasive GAS or NABS infections from all sites.MethodsClinical characteristics, in vitro susceptibility and antibiotic therapy were examined for unique inpatient encounters with iBHS (GAS + NABS) infections in the Cerner HealthfactsTM Database. β-Lactam treated cases receiving clindamycin were matched 1:1 to non-clindamycin cases by propensity of receiving clindamycin using nearest neighbor propensity score matching with downstream adjustment using logistic regression. In-hospital mortality, length of stay (LOS) and Sequential Organ Failure (SOFA) score trajectory was compared based on the matched sample.ResultsOf 1,956 inpatients with iBHS infection treated with β-lactams at 118 hospitals between 2000 and 2015, 459 (23.5%) received adjunctive clindamycin. Propensity score matching generated 389 case-pairs with good covariate balance (Table 1, Figure 1). In-hospital mortality did not differ between matched clindamycin and non-clindamycin cases (7.2% vs. 8.0%, P = 0.66, aOR 0.88, [95% CI .49–1.57]) (Figure 2). Receipt of clindamycin early (within 24h vs. no clindamycin) also did not display a survival advantage (aOR 1.04 [0.51–2.14]). On day 4 of therapy Median SOFA score (P = 0.586) and SOFA delta (day 0–day 4) were similar between the two groups (P = 0.13; Figure 3). Amongst survivors, median [IQR] LOS was greater in the clindamycin group (8[5,12] vs. 6[4,9]; P = 0.001)ConclusionAdjunctive clindamycin was not associated with decreased mortality or degree of organ dysfunction among patients with iBHS infection already treated with β-lactams. Figure 2: Odds Ratio of In-Hospital Mortality Abbreviations: GAS: Group A Streptococcus , ICU: intensive care unit, iβHS: invasive β-Hemolytic streptococcus, NABS: Non group A β-Hemolytic streptococci , OR: odds ratioFigure 2 Legend: The figure reports the odds ratios (ORs) of in-hospital mortality and 95% confidence intervals in the unmatched and unadjusted analysis, matched and unadjusted analysis, and primary analysis of all propensity-matched pairs with downstream adjustment with logistic regression for proven ißHS, vasopressor use and ICU (within 24h of culture sampling), as well as sensitivity analyses on propensity matched pairs of 2:1 match and subgroup analysis on propensity matched pairs of (1) proven ißHS alone (2) probable ißHS alone (3) ICU admission (within 24h of culture sampling) (4) patients receiving vasopressor therapy (within 24h of culture sampling) (5) Group A ißHS alone (6) Non Group A ißHS alone. There was no statistically significant difference in the ORs for in-hospital mortality between clindamycin and propensity-matched non-clindamycin cases in the primary analysis (*) as well as all sensitivity and subgroup (†) analyses.Figure 3: SOFA Score Trajectory by Survival Status Abbreviations: B: Non-Clindamycin cases, BC: Clindamycin CasesFigure 3 Legend: SOFA score by day of therapy of clindamycin and non-clindamycin matched cases based on survival status from day zero (day prior to antibiotic therapy) to day four of therapy. The linear mixed models were used to assess the time trends and the clindamycin effect on the longitudinal SOFA scores. SOFA trajectory was examined for the post matching sample. Square root transformation was applied to the SOFA score to meet the normality assumption Mean Baseline SOFA scores prior to therapy were similar amongst clindamycin and non-clindamycin subjects (mean [standard deviation(SD)] SOFA score: 1.88[2.48] vs. 1.96[2.60]; p= 0.634). On day 4 of therapy SOFA scores were similar between remaining 310 clindamycin and 286 non-clindamycin hospitalized patients (mean[SD] SOFA score: 1.79[2.88] vs. 1.67 [2.49]; p=0.586). The SOFA delta (day 0 SOFA score - day 4 SOFA score) was similar between the two groups (p=0.1331). When examined amongst survivors only, SOFA scores on day 4 of therapy were similar between and 272 non-clindamycin and 310 clindamycin hospitalized patients (mean[SD] SOFA score: 1.45 [2.20] vs. 1.52 [2.44])This work was funded in part by the Intramural Research Program of the National Institutes of Health Clinical Center and the National Institute of Allergy and Infectious Diseases.The opinions expressed in this abstract are those of the authors and do not represent any position or policy of the National Institutes of Health, the United States Department of Health and Human Services, or the United States government.Disclosures All authors: No reported disclosures.

Acute Kidney Injury after Lung Transplantation: A Systematic Review and Meta-Analysis.

Background: Lung transplantation has been increasingly performed worldwide and is considered an effective therapy for patients with various causes of end-stage lung diseases. We performed a systematic review to assess the incidence and impact of acute kidney injury (AKI) and severe AKI requiring renal replacement therapy (RRT) in patients after lung transplantation. Methods: A literature search was conducted utilizing Ovid MEDLINE, EMBASE, and Cochrane Database from inception through June 2019. We included studies that evaluated the incidence of AKI, severe AKI requiring RRT, and mortality risk of AKI among patients after lung transplantation. Pooled incidence and odds ratios (ORs) with 95% confidence interval (CI) were obtained using random-effects meta-analysis. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42019134095). Results: A total of 26 cohort studies with a total of 40,592 patients after lung transplantation were enrolled. Overall, the pooled estimated incidence rates of AKI (by standard AKI definitions) and severe AKI requiring RRT following lung transplantation were 52.5% (95% CI: 45.8–59.1%) and 9.3% (95% CI: 7.6–11.4%). Meta-regression analysis demonstrated that the year of study did not significantly affect the incidence of AKI (p = 0.22) and severe AKI requiring RRT (p = 0.68). The pooled ORs of in-hospital mortality in patients after lung transplantation with AKI and severe AKI requiring RRT were 2.75 (95% CI, 1.18–6.41) and 10.89 (95% CI, 5.03–23.58). At five years, the pooled ORs of mortality among patients after lung transplantation with AKI and severe AKI requiring RRT were 1.47 (95% CI, 1.11–1.94) and 4.79 (95% CI, 3.58–6.40), respectively. Conclusion: The overall estimated incidence rates of AKI and severe AKI requiring RRT in patients after lung transplantation are 52.5% and 9.3%, respectively. Despite advances in therapy, the incidence of AKI in patients after lung transplantation does not seem to have decreased. In addition, AKI after lung transplantation is significantly associated with reduced short-term and long-term survival.

Readmission to a different hospital following acute stroke is associated with worse outcomes.

There is a high risk of readmission within 30 days of index acute ischemic stroke (AIS), but effect of readmission to a different hospital is not known. We performed a retrospective cohort study to assess our hypothesis that 30-day readmission outcomes after AIS are worse for those readmitted to another hospital vs the discharging hospital. We utilized the 2013 Nationwide Readmissions Database to identify patients with index stroke admissions with ICD-9-CM codes. We identified all-cause readmissions with Clinical Classification Software. Outcomes included length of stay (LOS), total charges of hospitalization, and in-hospital mortality during 30-day readmission. Using linear and logistic regression, outcomes were compared in those readmitted to another hospital vs the discharging hospital. There were 194,549 patients included, with an average age of 80.0 ± 14.0 years; 51.2% were female; 24,545 were readmitted within 30 days, and 7,274 (29.6%) to a different hospital. Readmission to a different hospital was associated with an increased LOS of 1.0 days (95% confidence interval [CI] 0.7-1.2, p < 0.0001) and $7,677.28 (95% CI $5,496-$9,858, p < 0.0001) greater total charges. The odds ratio for in-hospital mortality during readmission was 1.2 for readmission to another hospital (95% CI 1.0-1.3, p = 0.0079). Readmission to another hospital within 30 days of AIS index admission was independently associated with longer LOS, increased total charges, and greater in-hospital mortality compared to readmission to the same hospital.

P1515Female sex is an independent predictor of mortality in patients with STEMI in Spain: a study in 325,017 episodes over 11 years (2005–2015)

Abstract Background Recent studies reported a decrease in the mortality of ST-elevation myocardial infarction (STEMI) patients. This favorable evolution could not extend to women. The interaction between gender and mortality in STEMI remains controversial. Purpose To assess the impact of female sex on mortality of patients with STEMI through of period of 11 years. Methods We conducted a retrospective longitudinal study using information provided by the minimal database system of the Spanish National Health System to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015. Results A total of 325,017 STEMI were identified. Of them, 273,182 were included, and 106,277 (38.8%) were women. Women were older than men and had more comorbidities. Through the study period 53% men vs 37.2% underwent PTCA; women presented more frequently heart failure, shock and stroke than men (p&lt;0.001, respectively). The mean crude in-hospital mortality rate for the whole study period was higher in women (OR: 2.18; 95% CI: 2.12.-2.23, p&lt;0.0001). Female sex was independently associated with higher in-hospital mortality (adjusted OR: 1.18; 95% CI: 1.14–1.22, p&lt;0.001) (Table 1). The risk was maintained through the whole study period (lower OR: 1.14 in 2014; higher OR: 1.28 in 2006). Table 1. Variables independently associated with in-hospital mortality adjusted by risk in a multilevel logistic regression model, 2005–2015 STEMI In-hospital mortality Odds Ratio P 95% CI Woman 1.18 &lt;0.001 1.14 1.22 Age 1.06 &lt;0.001 1.06 1.06 History of PTCA 1.58 &lt;0.001 1.40 1.77 Congestive heart failure 1.26 &lt;0.001 1.22 1.30 Acute Myocardial Infarction 1.84 &lt;0.001 1.54 2.20 Anterior myocardial infarction 1.47 &lt;0.001 1.23 1.76 Cardio-respiratory failure or shock 15.25 &lt;0.001 14.78 15.75 Hypertension 0.81 &lt;0.001 0.79 0.84 Stroke 5.76 &lt;0.001 5.18 6.42 Cerebrovascular disease 0.86 &lt;0.001 0.79 0.93 Renal failure 1.95 &lt;0.001 1.88 2.02 Vascular disease and complications 7.03 &lt;0.001 5.72 8.63 CI, Confidence Interval. Conclusions Female sex is an independent predictor of mortality in patients with STEMI in Spain, maintaining through a period of the 11 years.

Potential disease burden of patients with substance abuse undergoing major abdominal surgery: A propensity score-matched analysis

BackgroundOver 19 million Americans have a substance abuse disorder. The current study sought to characterize the relationship between substance abuse with in-hospital outcomes following major, elective abdominal surgery. MethodsThe Nationwide Inpatient Sample was used to identify patients who underwent major abdominal surgery between 2007 to 2014. Patients with preoperative substance abuse, including alcohol, opioids, and non-opioid drugs, were identified. Propensity score matching was used to examine the association of substance abuse with perioperative outcomes. ResultsAmong 301,659 patients, 7,925 patients (2.6%) had a history of substance abuse. Pancreatectomy was the surgical procedure with the highest proportion of patients with substance abuse history (n = 844, 4.7%). Compared with patients without a substance abuse history, patients with a substance abuse history were more likely to be younger (median age, 60 years [interquartile range (IQR) 52–69] vs 63 years [IQR 52–72]), male (n = 5,438, 67.5% vs n = 132,961, 54.7%), and be in the lowest income category (n = 2,062, 26% vs n = 64,345, 21.9%) (all P < .001). On propensity score matching, substance abuse was associated with increased odds ratio of experiencing a complication (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.55–1.82), non-home discharge (OR 1.95, 95% CI 1.76–2.16), extended length of stay (OR 1.88, 95% CI 1.76–2.02), and higher expenditure (OR 1.62, 95% CI 1.49–1.77). Stratified by the type of substance abuse, patients with history of alcohol (OR 1.57, 95% CI 1.44–1.71) and drug abuse (OR 1.26, 95% CI 1.14–1.39) were more likely to experience a complication, whereas only history of alcohol abuse was associated with higher odds ratio of in-hospital mortality (OR 1.38, 95% CI 1.07–1.79) (all P < .05). ConclusionUp to 1 in 50 patients undergoing complex abdominal surgery had a substance abuse history. History of substance abuse was associated with an increased risk of adverse perioperative outcomes and higher healthcare expenditures.