Secondary Discharge Diagnosis Research Articles

Rule-based natural language processing to examine variation in worsening heart failure hospitalizations by age, sex, race and ethnicity, and left ventricular ejection fraction

BackgroundPrior studies characterizing worsening heart failure events (WHFE) have been limited in using structured healthcare data from hospitalizations, and with little exploration of sociodemographic variation. The current study examined the impact of incorporating unstructured data to identify WHFE, describing age-, sex-, race and ethnicity-, and left ventricular ejection fraction (LVEF)-specific rates. MethodsAdult members of Kaiser Permanente Southern California (KPSC) with a HF diagnosis between 2014-2018 were followed through 2019 to identify hospitalized WHFE. The main outcome was hospitalizations with a principal or secondary HF discharge diagnosis meeting rule-based Natural Language Processing (NLP) criteria for WHFE. In comparison, we examined hospitalizations with a principal discharge diagnosis of HF. Age-, sex-, and race and ethnicity-adjusted rates per 100 person-years (PY) were calculated among age, sex, race and ethnicity (non-Hispanic (NH) Asian/Pacific Islander [API], Hispanic, NH Black, NH White) and LVEF subgroups. ResultsAmong 44,863 adults with HF, 10,560 (23.5%) had an NLP-defined, hospitalized WHFE. Adjusted rates (per 100 PY) of WHFE using NLP were higher compared to rates based only on HF principal discharge diagnosis codes (12.7 and 9.3, respectively), and this followed similar patterns among subgroups, with the highest rates among adults ≥75 years (16.3 and 11.2), men (13.2 and 9.7), and NH Black (16.9 and 14.3) and Hispanic adults (15.3 and 11.4), and adults with reduced LVEF (16.2 and 14.0). Using NLP disproportionately increased the perceived burden of WHFE among API and adults with mid-range and preserved LVEF. ConclusionRule-based NLP improved the capture of hospitalized WHFE above principal discharge diagnosis codes alone. Applying standardized consensus definitions to EHR data may improve understanding of the burden of WHFE and promote optimal care overall and in specific sociodemographic groups.

Association of multiple sclerosis with incident diabetes: A nationwide cohort study

AimDiabetes mellitus (DM) and multiple sclerosis (MS) are two common diseases known to worsen the trajectory of each other, yet it is unknown whether MS is associated with incident DM. MethodsUsing Danish nationwide registries, we identified all patients aged 18–99 with a first-time primary or secondary discharge diagnosis with MS between 2000 and 2018, with no known DM. These patients were matched with control subjects from the background population in a 1:5 ratio based on age and sex, to assess their risk of DM. ResultsA total of 13,376 patients with MS and 66,880 matched control subjects were included (33 % men; median age, 42 years [25th–75th percentile, 33–51]). During a median follow-up of 8.3 years (25th–75th percentile, 4.0–13.3), 467 (3.5 %) patients with MS and 2397 (3.6 %) control subjects were diagnosed with DM. The cumulative incidence of DM was similar among patients with MS and control subjects (95 % confidence interval [CI] 6.5 % [5.7–7.2 %] vs. 7.3 % [95 % CI 6.9–7.9 %], respectively), and adjusted analysis yielded a hazard ratio (HR) of 0.98 [95 % CI 0.89–1.09]). The overall risk of incident type 1 diabetes was low and yielded a HR of 1.60 [95 % CI 0.98–1.40] in patients with MS compared with control subject (P = 0.07). ConclusionThis study demonstrated that patients with MS had a similar risk of incident DM as compared to age- and sex matched controls from the background population.

Impact of frailty on hospitalized patients with prostate cancer: A retrospective analysis.

e23054 Background: The impact of Hospital frailty risk score on outcomes in hospitalized patients with prostate cancer has not been previously studied. This research aimed to examine the association between frailty and prostate cancer outcomes. Methods: This retrospective study utilized hospitalization data from the National Inpatient Sample (NIS) between January 1, 2020, and December 31, 2020. Data of patients with a primary or secondary discharge diagnosis of prostate cancer (ICD10-CM codes C61.0, D07.5, and Z85.46) were obtained. The objective was to evaluate the correlation between frailty and prostate cancer. Multivariate analysis was performed, stratified by race, age, Charlson index, median annual income in the patient's zip code, hospital bed size, teaching status, and census division of the hospital. Results: A total of 51,980 hospitalizations for prostate cancer were identified, with 72.7% in the intermediate to high frailty score (IHFS) group and 27.3% in the low frailty score (LFS) group. The IHFS group had a higher unadjusted in-hospital mortality rate than the LFS group (5.85% vs. 1.2%). Patients with IHFS had increased odds of adjusted mortality compared to those with LFS (adjusted odds ratio [aOR] = 4.45, 95% Cl [3.80-5.22], P < 0.01). Hispanic and Black race patients also had increased odds of adjusted mortality compared to Caucasian race patients (aOR = 1.42, 95%CI [1.19-1.70], P < 0.01); aOR = 1.16, 95%CI [1.00-1.32], P = 0.037, respectively). Additionally, the IHFS group had longer lengths of stay (5.65 ± 0.038 vs. 3.26 ± 0.28 days) and higher adjusted total costs ($66,107 ± 850 vs. $64,308 ± 1066) compared to the LFS group. Conclusions: Patients with prostate cancer and a high hospital frailty risk score exhibited significantly higher mortality rates, longer lengths of stay, and increased total adjusted costs. Frailty assessment plays a crucial role in predicting outcomes in patients with prostate cancer. Physicians can use frailty assessment to stratify patients based on risk and improve their ability to anticipate consequences.

Clinical outcomes, demographics and associative analysis of lung cancer patients with Lambert-Eaton myasthenic syndrome: Insights from the National Inpatient Sample (NIS) database.

e20134 Background: Lambert-Eaton myasthenic syndrome (LEMS) is a rare neuromuscular junction disorder that may present as a paraneoplastic syndrome or a primary autoimmune disorder. Approximately 60% of LEMS patients have an underlying tumor, with the paraneoplastic form predominantly associated with small cell lung cancer (SCLC). Understanding the clinical outcomes and risks associated in lung cancer patients with LEMS is crucial in effective management of such patients. Methods: This retrospective study utilized inpatient hospitalization data from the National Inpatient Sample (NIS) between January 1, 2016, and December 31, 2019. Data of patients with a primary or secondary discharge diagnosis of lung cancer (ICD10-CM codes C34, C78.0, C46.5, D02.2) were obtained. Then, out of this population, we identified Lambert-Eaton myasthenic syndrome with ICD-10 codes (G70.80, G70.81, G73.1). The objective was to run a descriptive analysis of clinical outcomes, risks, demographics and associations of LEMS in patients with lung cancer. Results: A total of 204 cases of lung cancer hospitalizations with LEMS were analyzed. The mean age was 68.23 years, with a slight female (51.72%) preponderance as compared to male (48.28%). Race distribution revealed increased prevalence in White Caucasians (83%), followed by Black (7%), Hispanic (4.5%), Asian or Pacific Islander (3%), Native American (0.5%), and Other (2%). The majority were covered by Medicare (66.33%), followed by private insurance (26.13%). The mortality rate was 8.9%, with a mean length of stay of 10.35 days and mean hospital charges of $118,676. Clinical outcomes and risks were analyzed, with sepsis occurring in 17.6% of cases, pneumonia in 22.5%, and acute respiratory failure in 26.9%. Intubation/mechanical ventilation was necessary in 18.1% of cases. The incidence of urinary tract infection (UTI) was 16.7%, acute kidney injury (AKI) was 17.2%, and venous thromboembolism (VTE) was 6.4%. Additionally, interventions such as intravenous immunoglobulin (IVIG) therapy and blood transfusions were also noted. Conclusions: This study provides insights into the demographic characteristics and clinical outcomes of lung cancer patients with Lambert-Eaton myasthenic syndrome (LEMS). The findings highlight the need for comprehensive management strategies targeting associated complications like acute respiratory failure, intubation and need for mechanical ventilation, pneumonia, UTI, AKI, and VTE to improve patient outcomes, quality of care and effective patient education with regards to their diagnosis of LEMS in lung cancer.

Pulmonary Rehabilitation Utilization in Older Adults with Chronic Obstructive Pulmonary Disease, 2013-2019.

Rationale: Pulmonary rehabilitation (PR) is very effective in patients with chronic obstructive pulmonary disease (COPD) for improving exercise tolerance and functional capacity, alleviating dyspnea, and improving respiratory quality of life. Access to and use of PR remain poor. Objectives: To assess the trends in PR use and factors associated with PR use in adults with COPD. Methods: We retrospectively analyzed the use of PR in adults with COPD using a 20% Medicare beneficiary population from January 1, 2013, to December 31, 2019. Adults with COPD were identified by 1) two or more outpatient visits >30 days apart within 1 year with an encounter diagnosis of COPD or 2) hospitalization with COPD as the primary diagnosis or a primary diagnosis of acute respiratory failure with a secondary discharge diagnosis of COPD. PR use in each calendar year was identified using Current Procedural Terminology and Healthcare Common Procedure Coding System codes. Factors associated with PR use were tested in bivariate and multivariable logistic regression models. Results: There was a gradual but modest increase in the percentage of patients with COPD using PR; the proportion increased from 2.5% in 2013 to 4.0% in 2019. Overall, the percentage of patients using PR remained low. Factors associated with higher odds of using PR included younger age (66-74 yr), White race, higher socioeconomic status, lower comorbidity score, residence in a metropolitan urban area, and sole or comanagement by a pulmonologist. Conclusions: The use of PR by Medicare beneficiaries with COPD has not changed meaningfully in the past decade and remains low.

Nationwide analysis of neuromyelitis optica in systemic lupus erythematosus and Sjogren's syndrome.

Neuromyelitis optica (NMO), also known as Devic's disease, is a rare inflammatory demyelinating disorder causing myelitis and optic neuritis. While there have been reports of systemic lupus erythematosus (SLE) and primary Sjogren's syndrome (SS) occurring with NMO, a formal association is not established. We aimed to investigate the occurrence of NMO in SLE and SS patients and study the clinical characteristics and outcomes of NMO and SLE/SS hospitalizations utilizing the national inpatient sample (NIS) database. The NIS database from 2016 to 2019 was used to extract data. Adult hospitalizations with the principal or secondary diagnosis of NMO were included. We classified NMO patients with and without concomitant diagnosis of SLE or Sjogren's syndrome. We evaluated and compared the clinical characteristics and outcomes of NMO hospitalizations with and without SLE or Sjogren's syndrome. STATA17 was used for data analysis. We also calculated the odds ratio of NMO in SLE and Sjogren's syndrome. There were a total of 16,360 adult hospitalizations with the principal or secondary discharge diagnosis of NMO. Among all NMO hospitalizations, 1425 (8.71%) had the primary or secondary diagnosis of SLE or SS. The odds of NMO in SLE and Sjogren's syndrome were noted to be 12.29 and 5.56, respectively. NMO with SLE/SS group had higher proportion of females (89.82% vs 79%, P value < 0.001), African Americans (56.63% vs 38.28, P value < 0.001), and Asians (5.73% vs 3.25, P value 0.04). The Charlson comorbidity index was higher for NMO-SLE/SS overlap (2.44 vs 1.28, P value < 0.001). There was no significant difference in overall mortality rates of both groups (2.11% vs 1.2%, P value 0.197). There were significantly higher reported seizures (14.73% vs 6.05, P value < 0.001) and paraplegia (21.75% vs 13.93%, P value < 0.001) in NMO-SLE/SS patients. These patients also had a longer length of stay in comparison to the reference group (7 vs 5 days, P value < 0.001) as well as higher total charges. NMO patients had a 12-fold higher risk of SLE and 5-fold higher risk of Sjogren's disease when compared to general population. Patients with overlap of NMO and SLE or Sjogren's were predominantly women and were more likely to be African-American. Co-existence of these autoimmune disorders was associated with poor prognosis in terms of higher morbidity for patients and increased health care burden. Key Points • NMO is a rare autoimmune disease seen predominantly in women in the middle age group with low overall mortality. • SLE and Sjogren's have increased odds of NMO in comparison to general population. • NMO patients have high rates of several complications such as paraplegia, quadriplegia, seizures, blindness, sepsis, and respiratory failure with even higher rates of seizures and paraplegia in those with concomitant SLE or Sjogren's.

Abstract 17709: ICD-10 Codes Have Low Sensitivity and Suboptimal Positive Predictive Value for Identifying Cases of Pulmonary Embolism With Cor Pulmonale in Electronic Healthcare Records

Introduction: The International Classification of Diseases, 10 th revision (ICD-10) codes were updated in 2015 to include designation of pulmonary embolism (PE) with cor pulmonale . These codes can be advantageous to identify higher-risk patients with PE for research or quality improvement. However, the validity of these codes is unknown. Methods: We reviewed patient data from Mass General Brigham (MGB) health system (01/2016-12/2021). Patients were randomly selected from 3 groups: Patients with Principal discharge diagnosis codes for PE, patients with secondary discharge diagnosis of PE, and patients with no PE codes. Accuracy of codes for PE with cor pulmonale were assessed with reference to manual review by 2 independent physicians using pre-specified criteria. Weighted estimates were obtained by considering the total number of hospitalizations. Results: 1,712 patients were included (age: 60.6±17.8 years, 52.3% female). Chart review found 865 patients with PE, of whom 360 (41.6%) had PE with cor pulmonale according to predefined clinical criteria. Of these 360 PE patients, 358 (99.4%) had ICD-10 codes for PE. However, only in 36 (10.1%) cases, the specific cor pulmonale codes were used. There were 24 additional cases with ICD-10 codes for PE with cor pulmonale in whom the diagnosis was not confirmed per manual review. Sensitivity and specificity for PE with cor pulmonale codes in Principal-or-secondary position were 10.0% and 98.2% (Table, panel A). The positive predictive value (PPV) for PE with cor pulmonale in Principal-or-secondary discharge position was 63.2% in the weighted sample (Table, panel B). Conclusions: ICD-10 codes for identification of acute PE with cor pulmonale have excellent specificity, but very poor sensitivity and suboptimal PPV. These results are informative for investigators who may use such ICD-10 codes for research or quality improvement purposes.

Abstract 17700: Double Trouble With Identification of Isolated Sub-Segmental Pulmonary Embolism Using ICD-10 Discharge Diagnosis Codes: The PE-EHR+ Study

Introduction: International Classification of Diseases 10 th revision (ICD-10) discharge diagnosis codes are widely used for research studies that use electronic databases. The accuracy of the codes for identifying patients with isolated sub-segmental pulmonary embolism (issPE) is unknown. Methods: We used data from the Mass General Brigham (MGB) health system (01/2016-12/2021) and included 1,734 patients randomly selected from 3 groups: Patients with ICD-10 Principal Discharge Diagnosis codes for PE, patients with secondary Discharge Diagnosis codes for PE, and patients with no ICD-10 codes for PE. Weighted estimates were obtained by considering the total number of hospitalizations in each category at MGB hospitals. Accuracy of the codes was assessed by two independent physicians who reviewed discharge summaries, daily notes, and radiology reports. Results: Of 1,734 records reviewed, 1,712 were included (age: 60.6±17.8 years, 52.3% female). Manual chart review found 865 patients with acute PE, including 104 (12.0%) with issPE. Of these 104 patients, 103 (98.3%) had ICD-10 codes for PE. However, only in 15 (14.6%) cases, PE codes were specified as being limited to subsegmental vessels (issPE). In turn, in another 43 cases, Principal-or-secondary ICD-10 codes for issPE were listed but the patients did not have acute issPE during index hospitalization per review of records. The sensitivity and specificity for issPE codes in Principal or secondary discharge position were 14.4% and 97.3% (Table, panel A). Positive predictive value in the weighted sample was only 26.2% (Table, panel B). Conclusions: ICD-10 codes are insensitive and have a poor positive predictive value for detection of isolated subsegmental PE and should not be used for case identification for research purposes or quality improvement initiatives.

Effectiveness, safety, and costs of thromboprophylaxis with enoxaparin or unfractionated heparin in inpatients with obesity.

Obesity is a frequent and significant risk factor for venous thromboembolism (VTE) among hospitalized adults. Pharmacologic thromboprophylaxis can help prevent VTE, but real-world effectiveness, safety, and costs among inpatients with obesity are unknown. This study aims to compare clinical and economic outcomes among adult medical inpatients with obesity who received thromboprophylaxis with enoxaparin or unfractionated heparin (UFH). A retrospective cohort study was performed using the PINC AI™ Healthcare Database, which covers more than 850 hospitals in the United States. Patients included were ≥18 years old, had a primary or secondary discharge diagnosis of obesity [International Classification of Diseases (ICD)-9 diagnosis codes 278.01, 278.02, and 278.03; ICD-10 diagnosis codes E66.0x, E66.1, E66.2, E66.8, and E66.9], received ≥1 thromboprophylactic dose of enoxaparin (≤40 mg/day) or UFH (≤15,000 IU/day) during the index hospitalization, stayed ≥6 days in the hospital, and were discharged between 01 January 2010, and 30 September 2016. We excluded surgical patients, patients with pre-existing VTE, and those who received higher (treatment-level) doses or multiple types of anticoagulants. Multivariable regression models were constructed to compare enoxaparin with UFH based on the incidence of VTE, pulmonary embolism (PE)---------related mortality, overall in-hospital mortality, major bleeding, treatment costs, and total hospitalization costs during the index hospitalization and the 90 days after index discharge (readmission period). Among 67,193 inpatients who met the selection criteria, 44,367 (66%) and 22,826 (34%) received enoxaparin and UFH, respectively, during their index hospitalization. Demographic, visit-related, clinical, and hospital characteristics differed significantly between groups. Enoxaparin during index hospitalization was associated with 29%, 73%, 30%, and 39% decreases in the adjusted odds of VTE, PE-related mortality, in-hospital mortality, and major bleeding, respectively, compared with UFH (all p < 0.002). Compared with UFH, enoxaparin was associated with significantly lower total hospitalization costs during the index hospitalization and readmission periods. Among adult inpatients with obesity, primary thromboprophylaxis with enoxaparin compared with UFH was associated with significantly lower risks of in-hospital VTE, major bleeding, PE-related mortality, overall in-hospital mortality, and hospitalization costs.

Association of Preexisting Heart Failure With Outcomes in Older Patients With Diffuse Large B-Cell Lymphoma

Anthracycline-containing regimens are highly effective for diffuse large B-cell lymphoma (DLBCL); however, patients with preexisting heart failure (HF) may be less likely to receive anthracyclines and may be at higher risk of lymphoma mortality. To assess the prevalence of preexisting HF in older patients with DLBCL and its association with treatment patterns and outcomes. This longitudinal cohort study used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry from 1999 to 2016. The SEER registry is a system of population-based cancer registries, capturing more than 25% of the US population. Linkage to Medicare offers additional information from billing claims. This study included individuals 65 years and older with newly diagnosed DLBCL from 2000 to 2015 with Medicare Part A or B continuously in the year prior to lymphoma diagnosis. Data were analyzed from September 2020 to December 2022. Preexisting HF in the year prior to DLBCL diagnosis ascertained from billing codes required one of the following: (1) 1 primary inpatient discharge diagnosis, (2) 2 outpatient diagnoses, (3) 3 secondary inpatient discharge diagnoses, (4) 3 emergency department diagnoses, or (5) 2 secondary inpatient discharge diagnoses plus 1 outpatient diagnosis. The primary outcome was anthracycline-based treatment. The secondary outcomes were (1) cardioprotective medications and (2) cause-specific mortality. The associations between preexisting HF and cancer treatment were estimated using multivariable logistic regression. The associations between preexisting HF and cause-specific mortality were evaluated using cause-specific Cox proportional hazards models with adjustment for comorbidities and cancer treatment. Of 30 728 included patients with DLBCL, 15 474 (50.4%) were female, and the mean (SD) age was 77.8 (7.2) years. Preexisting HF at lymphoma diagnosis was present in 4266 patients (13.9%). Patients with preexisting HF were less likely to be treated with an anthracycline (odds ratio, 0.55; 95% CI, 0.49-0.61). Among patients with preexisting HF who received an anthracycline, dexrazoxane or liposomal doxorubicin were used in 78 of 1119 patients (7.0%). One-year lymphoma mortality was 41.8% (95% CI, 40.5-43.2) with preexisting HF and 29.6% (95% CI, 29.0%-30.1%) without preexisting HF. Preexisting HF was associated with higher lymphoma mortality in models adjusting for baseline and time-varying treatment factors (hazard ratio, 1.24; 95% CI, 1.18-1.31). In this study, preexisting HF in patients with newly diagnosed DLBCL was common and was associated with lower use of anthracyclines and lower use of any chemotherapy. Trials are needed for this high-risk population.

Developing Validated Tools to Identify Pulmonary Embolism in Electronic Databases: Rationale and Design of the PE-EHR+ Study.

Contemporary pulmonary embolism (PE) research, in many cases, relies on data from electronic health records (EHRs) and administrative databases that use International Classification of Diseases (ICD) codes. Natural language processing (NLP) tools can be used for automated chart review and patient identification. However, there remains uncertainty with the validity of ICD-10 codes or NLP algorithms for patient identification. The PE-EHR+ study has been designed to validate ICD-10 codes as Principal Discharge Diagnosis, or Secondary Discharge Diagnoses, as well as NLP tools set out in prior studies to identify patients with PE within EHRs. Manual chart review by two independent abstractors by predefined criteria will be the reference standard. Sensitivity, specificity, and positive and negative predictive values will be determined. We will assess the discriminatory function of code subgroups for intermediate- and high-risk PE. In addition, accuracy of NLP algorithms to identify PE from radiology reports will be assessed. A total of 1,734 patients from the Mass General Brigham health system have been identified. These include 578 with ICD-10 Principal Discharge Diagnosis codes for PE, 578 with codes in the secondary position, and 578 without PE codes during the index hospitalization. Patients within each group were selected randomly from the entire pool of patients at the Mass General Brigham health system. A smaller subset of patients will also be identified from the Yale-New Haven Health System. Data validation and analyses will be forthcoming. The PE-EHR+ study will help validate efficient tools for identification of patients with PE in EHRs, improving the reliability of efficient observational studies or randomized trials of patients with PE using electronic databases.

Prevalence and prognosis of seizures among patients undergoing mechanical thrombectomy for acute ischemic stroke: A look at pre-2015 aha/asa guidelines update regarding endovascular treatment

BackgroundMechanical Thrombectomy (MT) is standard of care for eligible patients with Acute Ischemic Stroke (AIS) due to large vessel occlusion (LVO). With increasing use of MT, clinicians are more likely to encounter seizures, a potential complication of AIS treated with MT. Tracking future trends in the burden of post-stroke seizure associated with MT will require baseline pre-approval benchmark estimates of its frequency and outcomes. MethodsAll patients with AIS who underwent MT (International Classification of Diseases, Ninth Revision, Clinical Modification; ICD-9-CM procedure code: 39.74) were identified from the National Inpatient Sample (NIS) 2006-2014, using appropriate ICD-9-CM codes. We identified a subset of patients with seizures using ICD-9-CM secondary discharge diagnoses codes 780.3x and 345.x. We computed the rate of seizures overall and across pre-specified demographic, clinical, and healthcare system-related variables. Finally, we assessed the independent association of mortality with seizures using a multivariable logistic regression model. ResultsOf 30137 (weighted) patients with AIS who underwent MT, 1,363 (4.5%) had seizures. Patients who had seizures were younger, privately insured, or Medicaid beneficiaries, and frequently died in the hospital. There were no statistically significant differences between the seizures and no-seizures groups by race, sex, IV thrombolysis with recombinant tissue plasminogen activator, length of stay, and the number of medical comorbidities. However, patients who underwent MT and developed seizures had 75% higher odds of in-hospital mortality (adjusted OR 95% CI 1.75; 1.22-2.49). ConclusionIn this nationwide sample, prior to the 2015 AHA/ASA guidelines update supporting MT use, seizures occurred in one of twenty patients with AIS treated with MT, and occurrence of seizure was independently associated with a nearly two-fold increase in the odds of in-hospitality death.

Hospital Readmission Risk and Risk Factors of People with a Primary or Secondary Discharge Diagnosis of Diabetes.

Hospital readmission among people with diabetes is common and costly. A better understanding of the differences between people requiring hospitalization primarily for diabetes (primary discharge diagnosis, 1°DCDx) or another condition (secondary discharge diagnosis, 2°DCDx) may translate into more effective ways to prevent readmissions. This retrospective cohort study compared readmission risk and risk factors between 8054 hospitalized adults with a 1°DCDx or 2°DCDx. The primary outcome was all-cause hospital readmission within 30 days of discharge. The readmission rate was higher in patients with a 1°DCDx than in patients with a 2°DCDx (22.2% vs. 16.2%, p < 0.01). Several independent risk factors for readmission were common to both groups including outpatient follow up, length of stay, employment status, anemia, and lack of insurance. C-statistics for the multivariable models of readmission were not significantly different (0.837 vs. 0.822, p = 0.15). Readmission risk of people with a 1°DCDx was higher than that of people with a 2°DCDx of diabetes. Some risk factors were shared between the two groups, while others were unique. Inpatient diabetes consultation may be more effective at lowering readmission risk among people with a 1°DCDx. These models may perform well to predict readmission risk.

Associations of Greenness, Parks, and Blue Space With Neurodegenerative Disease Hospitalizations Among Older US Adults

Exposure to natural environments has been associated with health outcomes related to neurological diseases. However, the few studies that have examined associations of natural environments with neurological diseases report mixed findings. To evaluate associations of natural environments with hospital admissions for Alzheimer disease and related dementias (ADRD) and Parkinson disease (PD) among older adults in the US. This open cohort study included fee-for-service Medicare beneficiaries aged 65 years or older who lived in the contiguous US from January 1, 2000, to December 31, 2016. Beneficiaries entered the cohort on January 1, 2000, or January 1 of the year after enrollment. Data from US Medicare enrollment and Medicare Provider Analysis and Review files, which contain information about individual-level covariates and all hospital admissions for Medicare fee-for-service beneficiaries, were analyzed between January 2021 and September 2022. Differences in IQRs for zip code-level greenness (normalized difference vegetation index [NDVI]), percentage park cover, and percentage blue space cover (surface water; ≥1.0% vs <1.0%). The main outcome was first hospitalizations with a primary or secondary discharge diagnosis of ADRD or PD. To examine associations of exposures to natural environments with ADRD and PD hospitalization, we used Cox-equivalent Poisson models. We included 61 662 472 and 61 673 367 Medicare beneficiaries in the ADRD and PD cohorts, respectively. For both cohorts, 55.2% of beneficiaries were women. Most beneficiaries in both cohorts were White (84.4%), were not eligible for Medicaid (87.6%), and were aged 65 to 74 years (76.6%) at study entry. We observed 7 737 609 and 1 168 940 first ADRD and PD hospitalizations, respectively. After adjustment for potential individual- and area-level confounders (eg, Medicaid eligibility and zip code-level median household income), NDVI was negatively associated with ADRD hospitalization (hazard ratio [HR], 0.95 [95% CI, 0.94-0.96], per IQR increase). We found no evidence of an association of percentage park and blue space cover with ADRD hospitalization. In contrast, NDVI (HR, 0.94 [95% CI, 0.93-0.95], per IQR increase), percentage park cover (HR, 0.97 [95% CI, 0.97-0.98], per IQR increase), and blue space cover (HR, 0.97 [95% CI, 0.96-0.98], ≥1.0% vs <1.0%) were associated with a decrease in PD hospitalizations. Patterns of effect modification by demographics differed between exposures. The findings of this cohort study suggest that some natural environments are associated with a decreased risk of ADRD and PD hospitalization.

Analysis of Severe Illness After Postvaccination COVID-19 Breakthrough Among Adults With and Without HIV in the US

Understanding the severity of postvaccination SARS-CoV-2 (ie, COVID-19) breakthrough illness among people with HIV (PWH) can inform vaccine guidelines and risk-reduction recommendations. To estimate the rate and risk of severe breakthrough illness among vaccinated PWH and people without HIV (PWoH) who experience a breakthrough infection. In this cohort study, the Corona-Infectious-Virus Epidemiology Team (CIVET-II) collaboration included adults (aged ≥18 years) with HIV who were receiving care and were fully vaccinated by June 30, 2021, along with PWoH matched according to date fully vaccinated, age group, race, ethnicity, and sex from 4 US integrated health systems and academic centers. Those with postvaccination COVID-19 breakthrough before December 31, 2021, were eligible. HIV infection. The main outcome was severe COVID-19 breakthrough illness, defined as hospitalization within 28 days after a breakthrough SARS-CoV-2 infection with a primary or secondary COVID-19 discharge diagnosis. Discrete time proportional hazards models estimated adjusted hazard ratios (aHRs) and 95% CIs of severe breakthrough illness within 28 days of breakthrough COVID-19 by HIV status adjusting for demographic variables, COVID-19 vaccine type, and clinical factors. The proportion of patients who received mechanical ventilation or died was compared by HIV status. Among 3649 patients with breakthrough COVID-19 (1241 PWH and 2408 PWoH), most were aged 55 years or older (2182 patients [59.8%]) and male (3244 patients [88.9%]). The cumulative incidence of severe illness in the first 28 days was low and comparable between PWoH and PWH (7.3% vs 6.7%; risk difference, -0.67%; 95% CI, -2.58% to 1.23%). The risk of severe breakthrough illness was 59% higher in PWH with CD4 cell counts less than 350 cells/μL compared with PWoH (aHR, 1.59; 95% CI, 0.99 to 2.46; P = .049). In multivariable analyses among PWH, being female, older, having a cancer diagnosis, and lower CD4 cell count were associated with increased risk of severe breakthrough illness, whereas previous COVID-19 was associated with reduced risk. Among 249 hospitalized patients, 24 (9.6%) were mechanically ventilated and 20 (8.0%) died, with no difference by HIV status. In this cohort study, the risk of severe COVID-19 breakthrough illness within 28 days of a breakthrough infection was low among vaccinated PWH and PWoH. PWH with moderate or severe immune suppression had a higher risk of severe breakthrough infection and should be included in groups prioritized for additional vaccine doses and risk-reduction strategies.

S1260 Disparities Exist Among the Demographics of Patients with Alcohol-Related Hepatitis Who Leave Against Medical Advice

Introduction: Alcohol-related hepatitis is one of the most severe manifestations of alcohol-related liver disease and has been associated with significant morbidity, mortality, and financial burden. Patients with alcohol use disorders are at risk of leaving against medical advice (LAMA), however there is lack of data in the literature to show which patients are at higher risk. In this study, we investigate and report the specific demographic factors and comorbidities associated with LAMA. Methods: Patients with a primary or secondary discharge diagnosis of alcohol-related hepatitis (ICD-10 codes K70.4 and K70.1) between January 2016 to December 2019 were included in this study. Demographics, comorbidities, complications, and interventions were studied for patients who LAMA. Multivariate analysis was conducted to elucidate factors contributing to the increased risk of alcohol-related hepatitis Results: A total of 538,750 patients were admitted with a diagnosis of alcohol-related hepatitis. Of these, 31,500 (5.84%) patients LAMA. Older age, Hispanic ethnicity, private insurance, and higher income status were associated with decreased risk of LAMA while younger age (aOR-4.39, p< 0.001), African American race (aOR-1.35, p< 0.001), lack of insurance (aOR-1.85, p< 0.001), and patients in the lowest income quartile (aOR-1.25, p< 0.001) were associated with the highest risk of LAMA. A concomitant diagnosis of hepatitis C (aOR-1.38, p< 0.001) or opioid use disorder (aOR-1.39, p-0.053) was also associated with higher risk of LAMA. A complete list of demographics and results of multivariate analysis are depicted in Table. Conclusion: Our findings demonstrate that significant differences exist between patients with alcohol-related hepatitis who leave against medical advice and those that remain hospitalized until discharge. We believe that this study will help healthcare providers identify patients at risk of LAMA and help promote targeted education of specific subgroups in understanding their disease state to decrease adverse events. Table 1. - Demographics and results of multivariate logistic regression to identify predictors for LAMA after adjusting for confounding variables Routine Discharge N (%) LAMAN (%) p-value Adjusted Odds Ratio p-value Total no. 507,250 31,500 Age Categories < 0.001 18-45 173,880 (34.2) 15,730 (50.0) 4.39 < 0.001 45-65 285,600 (56.3) 15,065 (47.8) 3.02 < 0.001 >65 47,770 (9.4) 705 (2.2) Reference Sex < 0.001 Male 338,540 (66.7) 22,845 (72.5) Reference Female 168,710 (33.3) 8,655 (27.5) 0.77 < 0.001 Race 0.003 White 356,935 (70.4) 21,910 (69.6) 1.3 < 0.001 African American 51,275 (10.1) 3,660 (11.6) 1.35 < 0.001 Hispanic 66,580 (13.1) 3,860 (12.3) Reference Asian/Pacific Islander 6,145 (1.21) 350 (1.1) 1.1 0.556 Native American 11,825 (2.3) 745 (2.4) 1.28 < 0.05 Other 14,490 (2.9) 975 (3.1) 1.16 0.093 Insurance < 0.001 Medicare 103,815 (20.5) 4,125 (13.1) 1.43 < 0.001 Medicaid 191,160 (37.7) 15,470 (49.1) 1.68 < 0.001 Private 131,675 (26) 5,405 (17.2) Reference Uninsured 56,815 (11.2) 4,990 (15.9) 1.85 < 0.001 Income Quartile < 0.001 Lowest quartile 141,480 (27.9) 9,940(31.6) 1.25 < 0.001 Second quartile 130,500 (25.7) 7,870 (25) 1.08 0.11 Third quartile 129,805 (25.6) 7,700 (24.4) 1.05 0.255 Highest quartile 105,465 (20.9) 5,995 (19.0) Reference Charlson Comorbidity Index < 0.001 0-1 188,205 (37.1) 16290 (51.7) 1.36 < 0.001 2 69165 (13.6) 5130 (16.3) 1.33 < 0.001 3 or more 249,880 (49.3) 10080 (32) Reference Comorbidities HIV/AIDS 1,715 (0.3) 155 (0.50) 0.0412 0.87 < 0.001 Hepatitis B 3,790 (0.75) 215 (0.7) 0.567 N/A Hepatitis C 45,120 (8.90) 3,650 (11.6) < 0.001 1.38 < 0.001 Opioid use disorder 1,525 (30.1) 225 (71.4) < 0.001 1.39 0.053 Drug use 71,780 (14.2) 7,340 (23.3) < 0.001 1.37 < 0.001 Smoking 11,500 (2.3) 915 (2.9) 0.009 1.13 0.116

Risk of Acute Kidney Injury Among Older Adults With Heart Failure and With Reduced Ejection Fraction Treated With Angiotensin-Neprilysin Inhibitor vs Renin-Angiotensin System Inhibitor in Routine Clinical Care

The acute hemodynamic effects of sacubitril/valsartan, an angiotensin receptor neprilysin inhibitor (ARNI), may result in early changes in kidney function, raising concerns about acute kidney injury (AKI), particularly in those who are naïve to renin-angiotensin system inhibitors (RASis). We conducted a cohort study using U.S. Medicare fee-for-service claims data (2014-2017). Patients with HFrEF ≥ 65 years newly initiating ARNI or RASi, with no prior use of either drug class, were included. The primary outcome was hospitalization due to AKI as the primary discharge diagnosis, and the secondary outcome included AKI as a primary or secondary discharge diagnosis. AKI risks were described under an as-treated follow-up approach, with censoring on treatment discontinuation, switch, insurance disenrollment, death, or administrative censoring as well as an intent-to-treat approach. Propensity-score-based fine-stratification weighting was used to account for potential confounding by 81 pre-exposure characteristics. Cumulative incidence functions were used to report absolute risks, and Cox proportional hazards models were used to provide hazard ratios (HR) and 95% confidence intervals (CI). We included 27,166 patients with a mean (SD) age of 73 (7.3) years, and 4155 (15.3%) were initiating ARNI. After propensity score weighting, the 180-day cumulative incidence was 2.7% (2.4%-3.1%) among RASi initiators and 2.7% (2.2%-3.5%) among ARNI initiators for the primary outcome, and it was 6.5% (6.0%-7.1%) and 6.1% (5.2%-7.1%), respectively, for the secondary outcome under as-treated follow-up. HR (95% CI) comparing ARNI with RASi were 0.91 (95% CI: 0.72-1.16) for the primary outcome and 0.92 (95% CI: 0.79-1.08) for the secondary outcome. Similar results were observed in the intent-to-treat analysis. Among a large cohort of U.S. Medicare beneficiaries with HFrEF, ARNI treatment was not associated with higher rates of AKI than RASi treatment. These results provide reassurance for providers considering ARNI initiation in older patients who are RASi-naïve.

Effects of greenness, public parks, and blue space on neurodegenerative disease hospitalizations in the US Medicare cohort

Background and Aim: Exposure to natural environments has been associated with health outcomes that are related to neurological disorders. However, the few studies that examined associations of natural environments with neurological disorders reported mixed findings. Our goal was to evaluate associations of multiple features of natural environments with Alzheimer’s disease and related dementia’s (ADRD) and Parkinson’s disease (PD) hospital admissions. Methods: We created an open cohort including all fee-for-service Medicare beneficiaries aged 65+, who lived in the contiguous US January 1, 2000 through December 31, 2016 (~63 million individuals). Zip code level greenness (Normalized Difference Vegetation Index, NDVI), percent public park cover, and percent blue space cover (&amp;#x2265;1 % cover vs. &amp;#x3c;1% cover) were assessed. We examined associations of these exposures with first ADRD or PD hospitalizations based on primary or secondary discharge diagnosis, using a novel Cox-equivalent Poisson model. We also assessed if associations varied by demographics and area-level socioeconomic status. Results: We observed 7,910,111 and 1,196,981 first ADRD and PD hospitalizations, respectively. After adjustment for potential individual- and area-level confounders, NDVI was negatively associated with ADRD hospitalization (HR=0.95, 95%CI: 0.94-0.96, per IQR increase). Percent public park cover and blue space cover were not associated with ADRD hospitalization. For PD hospitalization, we observed negative associations of NDVI (HR=0.94, 95%CI: 0.93-0.95, per IQR), percent public park cover (HR=0.97, 95%CI: 0.97-0.98, per IQR), and blue space cover (HR=0.97, 95%CI: 0.96-0.98, &amp;#x2265;1% v. &amp;#x3c;1%). Patterns of effect modification by demographics differed between the exposures. For example, for PD hospitalization, negative associations of NDVI were strongest in the mid and high SES neighbourhoods, while negative associations of percent public park cover were strongest in the low SES neighbourhoods. Conclusions: Features of natural environments are associated with a decreased risk of ADRD and PD hospitalization in this cohort of US-based older adults.

Prevalence, predictors, and prognosis of mortality among elderly stroke patients with convulsive status epilepticus in the United States

BackgroundStroke is the most common cause of epilepsy in the elderly. However, despite the high mortality typically associated with convulsive status epilepticus (CSE), there is a dearth of nationwide data on the magnitude and association of CSE with mortality among hospitalized elderly with stroke in the United States. MethodsWe analyzed the 2006–2014 National Inpatient Sample (NIS) to identify elderly patients (65+ years) with a primary discharge diagnosis of stroke using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes 433.X1, 434.X1, 436, 430, 431, 432.0, 432.1, and 432.9. We examined a subgroup with a secondary discharge diagnosis of convulsive status epilepticus (ICD-9-CM: 345.3). We estimated the hospital mortality rate by CSE status and then evaluated the independent association of CSE and other key factors with mortality among hospitalized elderly with stroke. ResultsA total of 1220 elderly patients (0.14%) had a secondary discharge diagnosis of CSE. Inpatient mortality rate was 25.8% among those with CSE vs. 7.7% for non-CSE patients. CSE was independently associated with a 4-fold increased odds of in-hospital death. Increased age, medical comorbidities, weekend admissions, being a Medicare beneficiary, and hospitalization in large urban teaching hospitals were also independently associated with a greater likelihood of in-hospital death. The small number of events did not allow analysis by stroke subtypes. ConclusionWhile CSE occurs in just 14 of 10,000 hospitalized elderly stroke patients in the United States, it is associated with a 4-fold higher odds of in-hospital death.

Identifying Alcohol Use Disorder in Patients With Cirrhosis Reduces 30-Days Readmission Rate.

Readmission is frequent among patients with cirrhosis and is a complex multifactorial process. To examine the association of alcohol use disorder (AUD) and risk of readmission in patients with alcohol-associated cirrhosis. National Readmission Dataset (2016-2017) was used to extract a retrospective cohort of 53,348 patients with primary or secondary discharge diagnosis code of alcohol-associated cirrhosis with their first admission (26,674 patients with vs. propensity matched 26,674 without a primary or secondary discharge diagnosis code of AUD). Readmission within 30-day was lower (43.9 vs. 48%, P< 0.001) among patients identified to have AUD at the time of discharge. In a conditional logistic regression model, a diagnosis of AUD was associated with 15% reduced odds of 30-day readmission, 0.85 (0.83-0.88). Furthermore, the reason for readmission among patients identified vs. not identified to have AUD was less likely to be liver disease complication. The findings remained similar in a matched cohort of patients where the AUD diagnosis at discharge was listed as one of the secondary diagnoses only. Although, our study findings suggest that identification of AUD at the time of discharge among patients hospitalized for alcohol-associated cirrhosis reduces the risk of 30-day readmission, unavailable information on patient counseling, referral for mental health specialist and treatment received for AUD limit the causality assessment. Future studies are needed overcoming the inherent limitations of the database to establish the role of identification and treatment of AUD in reducing readmission and liver decompensation in patients with alcohol-associated cirrhosis.