Primary ICD-9 Codes Research Articles

School Year and Suicidal Behaviors Among Youth: Insight From a National Dataset.

Objective: To compare suicidal behaviors that occur during the school year with those during school break and to examine demographic characteristics and comorbidities of the suicidal behaviors by time period.Methods: This retrospective cross-sectional analysis of a nationwide US sample included 74,385 inpatients (aged 10-18 years) who were admitted to the hospital with primary ICD-9 codes of suicidal ideation or suicide and self-inflicted injury including poisoning between January and December 2014. For this study, the sample was further subgrouped based on school year (September to May) and school break (June to August).Results: Suicidal behaviors were higher during the school year (average of 6,761/month) compared to school break (average of 4,512/month). Prevalence of suicidal behaviors was highest in October for both hospitalization and primary diagnosis of mood disorder. Among the school year cohort, the rate of suicidal behaviors was higher in youth with mood disorders (91.6% vs 90%). During school break, the suicidal behavior rate was higher for youth with disruptive behavior disorders (34.6% vs 31.5%) and comorbid alcohol (7.9% vs 5.7%) and other substance use disorders (21.7% vs 18.4%).Conclusions: Suicidal behaviors were higher (1.5 times) during the school year compared to school break. Given the finding that suicidal behaviors are higher among students with mood disorders during the school year, schools should implement universal depression and suicide screening. Youth with disruptive behavior disorders and substance use disorders are at higher risk for suicidal behaviors during school break, thus increased outreach and monitoring during extended breaks seems warranted for these high-risk youth during unstructured times.

Invasive Bacterial Infections in Infants With Skin and Soft-Tissue Infections

Research Article| September 01 2021 Invasive Bacterial Infections in Infants With Skin and Soft-Tissue Infections AAP Grand Rounds (2021) 46 (3): 27. https://doi.org/10.1542/gr.46-3-27 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Invasive Bacterial Infections in Infants With Skin and Soft-Tissue Infections. AAP Grand Rounds September 2021; 46 (3): 27. https://doi.org/10.1542/gr.46-3-27 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: bacterial infections, skin, skin and soft tissue infections, soft tissue infections, urinary tract infections, bacteremia Source: Lopez MA, Hall M, et al. Invasive bacterial infections in infants younger than 60 days with skin and soft tissue infections. Pediatr Emerg Care. 2021;37(6):e301-e306; doi: https://doi.org/10.1097/PEC.0000000000001584Google Scholar Investigators from multiple institutions conducted a retrospective cohort study to determine the frequency of invasive bacterial infection (IBI) in infants with skin and soft-tissue infections (SSTI). Infants were eligible if they were: (a) <60 days of age; (b) visited 1 of 35 EDs that contribute data to the Pediatric Health Information System (PHIS) between 2009–2014; and (c) were assigned a primary ICD-9 code for SSTI (eg, cellulitis, abscess, mastitis) or a secondary diagnosis of SSTI and a primary diagnosis of fever, IBI, urinary tract infection (UTI), or anal fistula. Infants with complex chronic conditions were excluded. Demographics as well as... You do not currently have access to this content.

Changes in atrial fibrillation admissions following daylight saving time transitions

BackgroundDaylight saving time (DST) imposes a twice-yearly hour shift. The transitions to and from DST are associated with decreases in sleep quality and environmental hazards. Detrimental health effects include increased incidence of acute myocardial infarction (MI) following the springtime transition and increased ischemic stroke following both DST transitions. Conditions effecting sleep are known to provoke atrial fibrillation (AF), however the effect of DST transitions on AF are unknown. MethodsAdmitted patients aged 18–100 with primary ICD9 code of AF between 2009 and 2016 were included. The number of admissions was compiled and means were compared for the Monday to Thursday period and the entire seven day interval following each DST transition and the entire year for the entire cohort and separated by gender. Significance was determined with Wilcoxon nonparametric tests. ResultsAdmission data for 6089 patients were included, with mean age of 68 years and 53% female. A significant increase was found in mean AF admissions over the Monday to Thursday period (3.09 vs 2.47 admissions/day [adm/d], P = 0.017) and entire week (2.48 vs 2.09 adm/d, P = 0.025) following the DST spring transition compared to the yearly mean. When separated by gender, women exhibited an increase in AF admissions following the DST spring transition (1.78 vs 1.28 adm/d for Monday to Thursday period, P = 0.036 and 1.38 vs 1.11 adm/d for entire week, P = 0.050) while a non-significant increase was seen in men. No significant differences were found following the autumn transition for the entire cohort or when separated by gender. ConclusionAn increase in AF hospital admissions was found following the DST springtime transition. When separated by gender, this finding persisted only among women. This finding adds to evidence of negative health effects associated with DST transitions and factors that contribute to AF episodes.

U.S. Hospitalization rates and reasons stratified by age among persons with HIV 2014–15

ABSTRACT Persons with HIV (PWH) are aging. The impact of aging on healthcare utilization is unknown. The objective of this study was to evaluate hospitalization rates and reasons stratified by age among PWH in longitudinal HIV care. Hospitalization data from 2014–2015 was obtained on all adults receiving HIV care at 14 diverse sites within the HIV Research Network in the United States. Modified clinical classification software from the Agency for Healthcare Research and Quality assigned primary ICD-9 codes into diagnostic categories. Analysis performed with multivariate negative binomial regression. Among 20,608 subjects during 2014–2015, all cause hospitalization rate was 201/1000PY. Non-AIDS defining infection (non-ADI) was the leading cause for admission (44.2/1000PY), followed by cardiovascular disease (CVD) (21.2/1000PY). In multivariate analysis of all-cause admissions, the incidence rate ratio (aIRR) increased with older age (age 18–29 reference): age 30–39 aIRR 1.09 (0.90,1.32), age 40–49 1.38 (1.16,1.63), age 50–59 1.58 (1.33,1.87), and age ≥ 60 2.14 (1.77,2.59). Hospitalization rates increased significantly with age for CVD, endocrine, renal, pulmonary, and oncology. All cause hospitalization rates increased with older age, especially among non-communicable diseases (NCDs), while non-ADIs remained the leading cause for hospitalization. HIV providers should be comfortable screening for and treating NCDs.

Clinical differences between visits to adult freestanding and hospital-based emergency departments

ObjectiveCompare clinical characteristics for adult visits to freestanding emergency departments (FEDs) and a hospital-based ED (HBED). MethodsElectronic health records were collected on adult ED visits from 7/1/14 to 6/30/15 from three FEDs and one level 1 trauma tertiary care HBED. ResultsThere were 55,909 HBED visits; 44,108 FED visits. The FED population was slightly more female (61% vs 57%), younger (48 vs 46 years), white (86% vs 60%), and employed (67% vs 49%). A higher percent of FED visits had private insurance (43% vs 20%); a lower percent had Medicaid (25% vs 42%) and Medicare (23% vs 30%). The top three presenting problems were the same at the HBED and FEDs, but the order differed: gastrointestinal (HBED 19% vs FED 18%), cardiorespiratory (18% vs 16%), injury-pain-swelling of extremity (14% vs 17%). Differences were seen in primary ICD9 codes. One quarter of FED visits and only 18% of HBED visits were for injury/poisoning. A higher percent of FED visits were for respiratory diseases (12% vs 9%) but a lower percent were for circulatory system diseases (7% vs 11%) and visits for mental illness (2% vs 6%). Nearly 30% of HBED visits resulted in admission, compared to 8% of FED visits. ESI level differed significantly, with a lower percent of high acuity cases at FEDs (level 1: 0.1% vs 1.6%; level 2: 5% vs 26%). ConclusionDifferences were observed in clinical characteristics of adult HBED visits versus FEDs. Results of this study can help communities plan their emergency care system.

Outcomes of Heart Block in Myocarditis: A Review of 31,760 Patients

Various electrocardiographic abnormalities, including atrioventricular conduction block, have been reported in patients with myocarditis. We performed an observation study to describe the characteristics and outcomes of inpatients diagnosed with myocarditis complicated by heart block (HB) in a large national cohort. We identified patients with primary ICD-9 codes for myocarditis HB from the Nationwide Inpatient Sample (NIS) Database from 1998 to 2013. We compared the baseline characteristics and compared clinical outcomes between patients with and without HB, and in patients with/without high degree atrioventricular block (HDAVB). From the NIS database, 31,760 patients had a principal diagnosis of myocarditis and HB was reported in 1.7% of these patients (n=540). Female gender and Asian race were independently associated with HB. Out of 540 patients, 363 patients had HDAVB (67.2%) and 177 patients had not advanced HB (32.8%). Not advanced HB was not associated with an increased mortality rate compared to patients without HB (0% vs. 2.7%, p=0.315). On the other hand, the incidence of cardiogenic shock, respiratory failure and renal failure were higher in patients with HDAVB (26.2% vs. 5.0%, 33.9% vs. 5.9% and 29.2% vs. 5.5%, p<0.001 respectively). Patients with HDAVB required more procedural support (incidence of intra-aortic balloon pump 17.8% vs. 3.3%). They also had significantly longer lengths of hospital stay (9.4±9.4 vs. 4.3±8.4, p<0.001) and higher mortality (15.5% vs. 2.7%, p<0.001). Compared to myocarditis patients without HB, the odds for mortality in myocarditis patients with HDAVB 1.58 (95% CI=1.03-2.49, p=0.039). The incidence of HB and HDAVB among patients with acute myocarditis was 1.7% and 1.1% respectively. Female gender and Asian race were both independently associated with significant odds for the occurrence of HB and HDAVB. High degree atrioventricular block was independently associated with increased morbidity and mortality.

A Case Series of the Probability Density and Cumulative Distribution of Laryngeal Disease in a Tertiary Care Voice Center.

To examine the distribution of clinic and operative pathology in a tertiary care laryngology practice. Probability density and cumulative distribution analyses (Pareto analysis) was used to rank order laryngeal conditions seen in an outpatient tertiary care laryngology practice and those requiring surgical intervention during a 3-year period. Among 3783 new clinic consultations and 1380 operative procedures, voice disorders were the most common primary diagnostic category seen in clinic (n = 3223), followed by airway (n = 374) and swallowing (n = 186) disorders. Within the voice strata, the most common primary ICD-9 code used was dysphonia (41%), followed by unilateral vocal fold paralysis (UVFP) (9%) and cough (7%). Among new voice patients, 45% were found to have a structural abnormality. The most common surgical indications were laryngotracheal stenosis (37%), followed by recurrent respiratory papillomatosis (18%) and UVFP (17%). Nearly 55% of patients presenting to a tertiary referral laryngology practice did not have an identifiable structural abnormality in the larynx on direct or indirect examination. The distribution of ICD-9 codes requiring surgical intervention was disparate from that seen in clinic. Application of the Pareto principle may improve resource allocation in laryngology, but these initial results require confirmation across multiple institutions.

Minimally Clinically Important Change in the Activity Measure for Post-Acute Care (AM-PAC), a Generic Patient-Reported Outcome Tool, in People With Low Back Pain.

The Activity Measure for Post-Acute Care (AM-PAC) is a generic metric of patient-reported functional status. The minimal clinically important difference (MCID) in the AM-PAC score has not been determined. The study objective was to determine the MCID for AM-PAC in people with low back pain. This was a retrospective cohort study. Anchor-based and distribution-based methods were used to estimate the MCID. The Modified Low Back Pain Disability Questionnaire was used as the anchor. Adults who had a primary ICD-9 code for low back pain in at least 1 outpatient physical therapist visit during an episode of care and who completed both the AM-PAC and the Modified Low Back Pain Disability Questionnaire in at least 2 visits during the care episode were included. The MCID was calculated for the AM-PAC basic mobility version as well its adapted version, which the Cleveland Clinic uses for patients 65 years old or older. A total of 1,271 participants were eligible for study. For the AM-PAC basic mobility version, anchor-based methods yielded MCID estimates of between 3.4 and 5.1, whereas distribution-based methods yielded estimates of 1.7 to 4.2. The minimal detectable change (MDC) for the AM-PAC basic mobility version was 3.3. For the adapted AM-PAC basic mobility version, the MCID was estimated to be between 2.9 and 4.0 via anchor-based methods and between 1.2 to 3.5 via distribution-based methods. The MDC for the adapted AM-PAC basic mobility version was 3.5. The estimated MCID was designed for people with low back pain only. The MCID ranged from 3.3 to 5.1 for the AM-PAC basic mobility version and 3.5 to 4 for the adapted version, with the MDC as the lower limit. Changes in the AM-PAC for people with low back pain may be interpreted using the estimated MCID. Future studies are needed to determine the AM-PAC MCID for populations other than those with low back pain.

Appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients.

BackgroundSkin and soft tissue infections (SSTIs) are a leading cause for hospitalizations in the United States. Few studies have addressed the appropriateness of antibiotic therapy in the management of SSTIs without complicating factors. We aimed to determine the appropriateness of antibiotic treatment duration for hospitalized adult patients with uncomplicated SSTIs.MethodsThis was a retrospective analysis performed at two academic medical centers in Pittsburgh, Pennsylvania on patients aged 18 years and older with primary ICD-9 code for SSTIs admitted August 1st, 2014–March 31st, 2015. The primary outcome was the appropriateness of antibiotic treatment duration for uncomplicated SSTIs. Secondary objectives included the appropriateness of antibiotic agent spectrum, duration of inpatient length of stay (LOS), utilization of blood cultures and advanced imaging modalities, and re-hospitalization for SSTI within 30 days of discharge from the index admission.ResultsA total of 163 episodes were included in the cohort. The mean duration of total antibiotic therapy was 12.6 days. Appropriate duration was defined as receipt of total antibiotic duration of less than 10 days and occurred in 20.2% of patients. Twenty eight percent of patients received antibiotics for greater than 14 days. Seventy three (44.8%) patients received greater than 24 h of inappropriate extended spectrum gram-negative coverage; 65 (39.9%) received anaerobic coverage.ConclusionsIn the majority of patients, treatment duration was excessive. Inappropriate broad spectrum antibiotic selection was utilized with regularity for SSTIs without complicating factors. The management of uncomplicated SSTIs represents a significant opportunity for antimicrobial stewardship.

Abstract T P365: Childhood Stroke: ICD-9 Code Positive Predictive Values for Identifying Hemorrhagic and Ischemic Events

Introduction: Childhood stroke event rates have been reported both using administrative databases and population-based epidemiological studies. The latter include verification of stroke as a case and categorization of type. Administrative databases allow cheaper, quicker estimation of rates and possible extrapolation of estimated rates to population-based rates. However, these estimations rely on the accuracy and interpretation of the ICD-9 coding. Methods: The Greater Cincinnati/Northern Kentucky Stroke Study measures temporal trends in the incidence rates in a biracial population of 1.3 million. Discharge lists with primary and secondary ICD-9 codes 430-436 from 16 area hospitals for 2010 were obtained; 437-438, 674 and 747 were also included at the Children’s hospital. Detailed information from medical records of potential cases was abstracted by trained research nurses and reviewed by stroke physicians, who determined if the event was a case and, also the event type (hemorrhagic stroke, infarction or transient ischemic attack(TIA)). Results: A total of 89 potential events in children &lt;20 years of age were reviewed, yielding 19 confirmed cases. Positive predictive values (PPV) for the primary ICD-9 codes for specific types varied from 0% to 100%. Primary and secondary ICD-9 codes, event types, and percent correct are presented in the Table. Conclusions: Childhood stroke cases captured through selected ICD-9 codes: 430-432, 434.x1, 434.9 and 435.9 (marked with an asterisk in the table) in the primary position would yield 14 strokes/TIAs, and underestimate the number of events by 26%. However, using both primary and secondary codes they would yield 34 strokes//TIAs, and overestimate the number of events by 79%. Population-based epidemiology studies are essential to monitor the validity of using ICD-9 codes to estimate childhood stroke/TIA incidence.

A population-based analysis of emergent versus elective paraesophageal hernia repair using the Nationwide Inpatient Sample.

As the life expectancy in the United States continues to increase, more elderly, sometimes frail patients present with sub-acute surgical conditions such as a symptomatic paraesophageal hernia (PEH). While the outcomes of PEH repair have improved largely due to the proliferation of laparoscopic surgery, there is still a defined rate of morbidity and mortality. We sought to characterize the outcomes of both elective and emergent PEH repair using a large population-based data set. The Nationwide Inpatient Sample was queried for primary ICD-9 codes associated with PEH repair (years 2006-2008). Outcomes were in-hospital mortality and the occurrence of a pre-identified complication. Multivariate analysis was performed to determine the risk factors for complications and mortality following both elective and emergent PEH repair. A total of 8,462 records in the data, representing 41,723 patients in the US undergoing PEH repair in the study interval, were identified. Of these procedures, 74.2% was elective and 42.4% was laparoscopic. The overall complication and mortality rates were 20.8 and 1.1%, respectively. Emergent repair was associated with a higher rate of morbidity (33.4 vs. 16.5%, p < 0.001) and mortality (3.2 vs. 0.37%, p < 0.001) than elective repair. Emergent repair patients were more likely to be male, were older, and more likely to be minority. Logistic modeling revealed that younger age, elective case status, and a laparoscopic approach were independently associated with a lower probability of complications and mortality. Patients undergoing emergent PEH repair in the United States tend to be older, more likely a racial minority, and less likely to undergo laparoscopic repair. Elective repair, younger age, and a laparoscopic approach are associated with improved outcomes. Considering all of the above, we recommend that patients consider elective repair with a surgeon experienced in the laparoscopic approach, especially when symptoms related to the hernia are present.

Trends in Hospitalizations Among Children and Young Adults with Perinatally Acquired HIV

Contemporary trends in hospitalization patterns among perinatally HIV-infected (PHIV) patients are unknown. We describe rates and reasons for hospitalizations stratified by age group during 2003-2010 within a large cohort of PHIV patients. 579 PHIV patients engaged in care at 6 geographically diverse pediatric HIV centers affiliated through the HIV Research Network were included. Modified Clinical Classification Software assigned primary ICD-9 codes into diagnostic categories. Analysis was performed using negative binomial regression with generalized estimating equations. There were 699 all-cause hospitalizations. The overall rate for the full cohort was 19.9/100 person-years, and overall rates for 0-4, 5-16 and 17-24 year-olds were 25.1, 14.7 and 34.2/100 person-years, respectively. Declines were seen in unadjusted all-cause rates for the whole group [incidence rate ratio per year, 0.93 (0.87-0.99)] and for 5-16 [0.87 (0.76-0.99)] and 17-24 year-olds [0.87 (0.80-0.95)]. After adjustment for CD4, HIV-1 RNA and demographics, rates were no longer declining. Non-AIDS-defining infections and AIDS-defining illnesses together caused 349 (50%) admissions. Declines in these categories drove the overall declines in unadjusted rates. No increases over time were seen for cardiovascular, renal or any other diagnostic categories. While the declines in hospitalizations are reassuring, continued efforts are needed to address the persistently high infectious and non-infectious morbidity among PHIV patients. Innovative strategies may be most critical for 17-24 year-olds. Lack of increases in cardiovascular and renal admissions provides modest, preliminary reassurance against severe non-infectious complications from longstanding HIV infection and antiretroviral exposure.

Abstract P004: Impact of Atrial Fibrillation on Healthcare Utilization in the Community: The Atherosclerosis Risk in Communities (ARIC) Study

Background: Atrial fibrillation (AF) is associated with increased risk of hospitalization. However, little is known about the impact of AF on non-inpatient healthcare utilization or about sex or race differences in AF-related utilization. We examined rates of inpatient and outpatient utilization by AF status in the Atherosclerosis Risk in Communities (ARIC) study. Methods and Results: ARIC cohort participants with incident AF enrolled in fee-for-service Medicare, Parts A and B, for at least 12 continuous months between 1991 and 2009 were matched on age, sex, race and center to up to three participants without AF. Healthcare utilization was ascertained from inpatient and outpatient Medicare claims and classified based on primary ICD-9 code. The analysis included 944 AF and 2,761 non-AF participants. The average number of days hospitalized per year was 13.1 (95% confidence interval [CI]: 11.5-15.0) and 2.8 (95% CI: 2.5-3.1) for those with and without AF, respectively. The corresponding number of outpatient claims per year was 53.2 (95% CI: 50.4-56.1) and 23.0 (95% CI: 22.2-23.8) for those with and without AF, respectively (Table). Most utilization in AF patients was attributable to non-AF conditions, particularly other-cardiovascular disease (CVD)-related reasons; the adjusted rate ratio for days hospitalized per year for other-CVD-related reasons was 4.76 (95% CI: 3.51 - 6.44) for those with compared to those without AF. There was suggestive evidence that sex modified the association between AF and inpatient utilization, with AF related to greater utilization in women than men. The association between AF and healthcare utilization was similar in whites and blacks. Conclusions: This study highlights the considerably greater healthcare utilization (inpatient and outpatient) among those with AF; the differential in utilization due to other-CVD-related reasons was substantial. In addition to recommended heart rate or rhythm treatment, accompanying cardiovascular comorbidities should be evaluated and managed.

Abstract W MP51: ICD-9 Code Positive Predictive Value for Stroke Subtype in a Population-Based Epidemiology Study

Introduction: Population-based epidemiological studies contribute substantially to the knowledge of stroke incidence, temporal trends, stroke subtype distribution, and risk factor prevalence. Often data are gathered from ICD-9 codes in administrative databases. We instead gathered data through labor-intensive inspection of medical records to examine the positive predictive values (PPV) of stroke ICD-9 codes. Methods: The Greater Cincinnati/Northern Kentucky Stroke Study measures temporal trends in the incidence rates in a biracial population of 1.3 million. Discharge lists with primary and secondary ICD-9 codes 430-436 from the 15 area hospitals for 2010 were obtained. Detailed information from medical records of stroke and TIA cases was abstracted by trained research nurses and reviewed by a stroke physician, who determined if the event was a case and, if so, the stroke subtype (SAH, ICH, infarct, or TIA). Results: A total of 7691events were reviewed. Positive predictive values (PPV) for the primary ICD-9 codes for specific subtypes varied from 48.6% to 90.1%. All primary and secondary ICD-9 codes, stroke subtypes, and percent yield are presented in the Table. Interestingly, 293 cases were found coded under a different primary ICD-9 subtype. An additional 497 cases were found under secondary ICD-9 codes. Most events coded under 433.x0 were non-cases, as expected. Many cases coded 435 were not found to be true TIAs, and code 436 yielded very few cases. Conclusions: Stroke cases captured through codes 430-436 were not necessarily in the primary position or coded to the correct stroke subtype. Complete medical record review revealed varying degrees of accuracy for each code. This could cause stroke incidence rates to be significantly misreported if based solely upon primary subtype-defined ICD-9 codes. Population-based epidemiology studies generate the most reliable incidence estimates by combining stroke ICD-9 codes with medical record review.

Changes of Upper GI Bleeding Mortality Risk in U.S. Population over Three Decades

Purpose: There are studies reporting different mortality risks for UGIB. Our objective was to determine the changes of morality risk of UGIB in the last three decades based on the anatomical site and cause, using nationwide representative database. Methods: We analyzed the National Hospital Discharge Sample (NHDS) from 1979 to 2009 and included the patients with the primary ICD-9 codes for UGIB and calculated the mortality risk in each decade based on the anatomical site and cause of bleeding. Mortality risk changes based on race, gender, number of admission days, region and hospital bed size were analyzed in each decade too. Results: We assessed 47,283 of UGIB including 1,838 UGIB inpatient mortalities in this period. UGIB mortality risk decreased by 35.4% from 4.8% in first decade to 3.1% in third decade (P<0.001). A parsimonious model in each decade indicated that higher age and higher number of hospitalization days were significant risk factors for inpatient mortality of UGIB in all three decades, and female gender was associated with significantly lower risk in the second decade. The most significant decrease was observed in patients over 65 years and during the first day of admission. Gastric bleeding (P<0.001) and esophageal bleeding (P=0.018) showed significant decreasing mortality risk trends. Duodenal bleeding mortality risk was stable in three decades. Esophageal variceal bleeding had the highest mortality risk among other causes. Conclusion: UGIB morality risks, especially of the first hospital day and geriatric patients, significantly decreased over the last three decades, presumably from recent advances in emergency medical care and therapies. Mortality risk of gastric, but not duodenal, bleeding had the most significant reduction.Table: Table. Parsimonious multiple logistic regression model of patient risk factors for UGIB mortalityTable: Table. Number and mortality risk based on the disease category

Upper Gastrointestinal Bleeding Mortality Risk Changes in Patients With Comorbidities Over Three Decades

Purpose: Our objective was to show the changes in the mortality risk of each comorbidity used in the Rockall score in patients with upper GI bleeding (UGIB) during three decades, using a nationwide representative data. Methods: We analyzed the National Hospital Discharge Sample (NHDS) for UGIB outcomes through the last three decades from 1979 to 2009. We identified the patients with the primary ICD-9 codes representing a diagnosis of UGIB and then calculated the mortality risk, crude odds ratio and adjusted odds ratio of each comorbidity used in the Rockall score in each decade. Results: There is a dramatic decline in mortality risk of patients with renal failure, starting from 50% in the first decade and ending up 4.0% in the third decade. Mortality risk of patients with CHF also had a substantial decrease from 17.9% to 5.2% in the first and third decades, respectively. Patients with IHD, cancer, and liver failure all showed decrease in the mortality risk too. Overall adjusted odds ratio of UGIB mortality indicates that liver failure, CHF, renal failure and cancer are significant risk factors for UGIB. The decreasing trend of odds ratio for patients with CHF (P<0.001), IHD (P<0.02) and renal failure (P<0.001) were statistically significant in this period. In esophageal bleedings, there was an increase in the mortality risk for patients with renal failure, while other comorbidities had a decreased risk from the second to third decade. Mortality risk of gastric bleeding for patients with renal failure has had a dramatic change, starting with 37.5% in the first decade, and ending up 3.7% in the third decade. Mortality risk of patients with CHF had a significant decline from 15% in the first decade to 4.1% in the third decade. Other comorbidities did not show such significant changes in their mortality risk in this period. Duodenal bleeding mortality risk in patients with renal failure plummeted from 47.4% in the first decade to 3.4% in the third decade. CHF patients showed a significant decline in this period, with 20.7% to 8.4% in the first and third decades, respectively. Patients with liver failure, IHD and cancer did not show significant changes in the mortality risk in this period. Conclusion: Critical care improvements in patients with comorbidities may have reduced mortality risks, particularly in renal and heart failure cases. These reductions are less in other studied comorbidities, which might be related to the pharmaceutical and procedural risks for causing UGIB. Despite reduction in the mortality risk, extra caution should be taken in the management of UGIB cases with the studied comorbidities due to higher risk of mortality in them.Table: Table. UGIB mortality risk and adjusted odds ratio for different Rockall score comorbidities

Decreasing Trend of Upper Gastrointestinal Bleeding Mortality Risk Over Three Decades

Upper gastrointestinal bleeding (UGIB) causes over $1 billion in medical expenses annually. The purpose of this study was to examine changes of UGIB mortality risks and trends over the last three decades. We analyzed the National Hospital Discharge Sample from 1979 to 2009. Patients with primary ICD-9 code representing a diagnosis of UGIB were included. The UGIB mortality risks and trends in each decade by anatomical sites, bleeding causes, comorbidities, and other important variables were analyzed. UGIB mortality risk decreased by 35.4 % from 4.8 % in the first decade to 3.1 % in the third decade (P < 0.001). Age and number of hospitalization days were significant risk factors in all decades. Most significant decreases were observed in patients over 65 years and during the first day of admission. Gastric (P < 0.001) and esophageal (P = 0.018) bleedings showed significant decreasing mortality risk trends. Duodenal bleeding mortality risk was stable in three decades. Mortality risk declined significantly among patients with renal failure (from 50.0 to 4.0 %) and heart failure (from 17.9 to 5.2 %; both P < 0.001) while changes in cases with ischemic heart disease, cancer, and liver failure were less significant. UGIB morality risks, especially of the first hospital day and geriatric patients, significantly decreased over the last three decades, presumably from recent advances in emergency medical care. Mortality risk of gastric, but not duodenal, bleeding had the most significant reduction. Critical care improvements in patients with various comorbidities may explain significant UGIB mortality risk reductions. This study provides invaluable insight into the causes and trends of UGIB mortality risks for future studies.

Abstract WMP91: The Mortality Rate Of Stroke Patients Is Less When Treated At Telestroke Spokes Vs. Non Telestroke Sites

Background: Most rural hospitals in Arkansas did not administer t-PA prior to participating in a telestroke program. With the growing number of telestroke networks, it is crucial to determine the effectiveness of these programs in improving the outcome of ischemic stroke patients. Methods: The Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) team reviewed the hospital discharge data of AR SAVES hospitals versus propensity score matched control hospitals linked with death certificates from 2006 to 2010 provided by the Arkansas Department of Health. All patients with primary ICD-9 codes for ischemic stroke were included. Hospitals with less than 10 admissions for ischemic stroke during the study period were excluded. ARSAVES hospitals were included in the evaluation if they started participating in the first 12 months of program initiation. All hospitals in the state that were not in the ARSAVES program prior to Jan 1, 2011 were the control group. Analyses were done using chi-square tests and t-tests. We used multivariable logistic regression models to compare differences in dichotomous outcomes. Results: A total of 18 hospitals and 3,728 ischemic stroke patients were included in the final analysis. Patients treated in participating hospitals had reduced mortality rates at 30 days (ARR 0.58, 95% CI 0.40-0.85), 6 months (ARR 0.57, 95% CI 0.42-0.77) and 12 months (ARR 0.66, 95% CI 0.48-0.90), as well as reduced rates of discharge to hospice care (ARR 0.53, 95% CI 0.29-0.99). There were no statistically significant differences in either length of hospital stay (AME 0.35 days, 95% CI -0.31 to 1.01) or hospital cost (AME $629, 95% CI -834 to 2,091). Conclusion: Stroke patients treated at telestroke spoke hospitals had a significantly lower mortality rate than those treated at a non telestroke hospital, with the same cost of care. This may be a reflection of increased t-PA use and improved stroke education and stroke patient care in telestroke hospitals.

Analysis of Antithrombotic Therapy after Cardioembolic Stroke Due to Atrial Fibrillation or Flutter

Background Guidelines recommend that all patients with atrial fibrillation and a history of ischemic stroke should receive an anticoagulant. Prior analyses show that warfarin is underutilized in most populations. Objective To examine the use of antithrombotic and anticoagulant therapy in patients with atrial fibrillation or flutter during the index hospitalization for acute, ischemic stroke. Methods Retrospective electronic medical record review of 200 patients treated at a tertiary care hospital with a primary ICD-9 code for ischemic stroke and a secondary ICD-9 code for atrial fibrillation or flutter. Exclusion criteria were active bleeding, pregnancy, age less than 18, pre-existing warfarin allergy, or dabigatran use. Results Fifty-two percent of patients received at least one dose of warfarin during the index hospitalization. There was no relationship between CHADS2 score and likelihood of receiving warfarin ( P &gt; .05). There was no significant difference in adverse event rate in patients receiving warfarin compared to those receiving aspirin (3.8% vs 9.1%; P = .14), but the rate of hemorrhagic transformation was lower in patients receiving warfarin (1% vs 7%; P = .03). The composite of hemorrhagic stroke or hemorrhagic transformation was significantly lower in patients receiving bridging therapy (0% vs 11%; P = .03). Sixteen patients were readmitted for stroke within 3 months of discharge. Ten were readmitted for ischemic stroke, 3 for hemorrhagic stroke or hemorrhagic transformation, and 3 for systemic bleeding. Ten patients (62.5%) were receiving warfarin at readmission, but only one of these patients had a therapeutic INR. Conclusions Warfarin was underutilized as secondary stroke prophylaxis in these high-risk patients. Bridging therapy appeared to be safe and was not associated with an increase in adverse events.

437 Quantifying the Temporal Increases in Charges for Uninsured Emergency Department Services

Study Objectives: Charges associated with medical care are increasing and variable, but little data exist examining charges for emergency care. Charge data may not reflect the cost of care or the ultimate monetary collection for care rendered for many populations. However, charge data may be associated with the absolute economic burden that the uninsured patients face from seeking care in the emergency department (ED). The purpose of this study is to quantify the change in ED charges over time for the uninsured population for 3 varying but commonly encountered ED diagnoses. We examined mean per-visit ED charges, and per-visit ED charges for several specific diagnoses. We hypothesize that a yearly increase in charge would be similar to the annual increase in domestic health expenditures. Methods: This is an ecological study examining ED visits over a 4-year period from 2006 to 2009. This study was approved by our institutional review board. Data were obtained from the Nationwide Emergency Department Sample (NEDS), the largest all-payer ED database in the United States, managed by the Healthcare Utilization Project. Basic demographic, clinical, and time-series data were obtained with appropriate weighting applied to the visits to make national-level estimates. We obtained weighted counts of all national ED visits and ED visits designated as self pay in the NEDS database. Among the self-pay population, we examined charge data among those patients with primary ICD-9 ED diagnoses of 3 common conditions with a low number of expected comorbidities: chest pain, ankle sprain, and acute appendicitis. All statistical analyses were conducted using SAS, Version 9.2. Results: There were 496,195,793 total weighted ED visits in the total study period. Of those, 82,833,783 visits were marked as self-pay and 3,699,547 self-pay visits had the primary ICD-9 codes of interest. Self-pay patients with a primary ICD-9 diagnosis of chest pain had a mean total ED charge of $2,385 (95% CI 2,250-2,519), $2,846 (95% CI 2,643-3,049), $3,137 (95% CI 2,940-3,335), and $3,578 (95% CI 3,338-3,819) during the years 2006, 2007, 2008, and 2009 respectively. Self-pay patients with a diagnosis of ankle sprain had a mean total ED charge of $861 (95% CI 827-894), $931 (95% CI 891-970), $1,044 (95% CI 1,003-1,085), and $1,112 (95% CI 1,069-1,156) during the years 2006, 2007, 2008, and 2009 respectively. Self-pay patients with a primary ICD-9 diagnosis of acute appendicitis had a mean total ED charge of $4,722 (95% CI 4197-5247), $6,461 (95% CI 5,487-7,434), $6,852 (95% CI 5,856-7,848), and $7,259 (95% CI 6,574-7,945) during the years 2006, 2007, 2008, and 2009 respectively. Mean charges increased by 50%, 29%, and 54% for self-pay patients with a primary ICD-9 diagnosis of chest pain, ankle sprain, and acute appendicitis, respectively, over the 4-year study period. Conclusion: ED charges affecting the uninsured population for 3 commonly encountered ED diagnoses are increasing at alarmingly high rates. This preliminary analysis from a large and powerful database warrants further validation and additional investigation to examine why the economic burden on this vulnerable population may be dramatically increasing.