Similar In-hospital Mortality Rates Research Articles

Staged versus concomitant transcatheter aortic valve replacement and percutaneous coronary intervention: A national analysis

ObjectiveAlthough patients with significant coronary artery disease and aortic stenosis have traditionally undergone open valve replacement and bypass grafting, percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR) are increasingly considered. Because of the lack of data regarding timing of PCI/TAVR, in the present study we evaluated associations of staged and concomitant PCI/TAVR on outcomes in a nationally representative cohort. MethodsAdults who underwent TAVR and PCI were identified using the 2016 to 2018 Nationwide Readmissions Database. If PCI/TAVR occurred on the same day, patients were considered Concomitant and otherwise considered Staged. Staged were further classified as Early-Staged if both occurred in the same hospitalization or Late-Staged if TAVR ensued PCI in a subsequent hospitalization. Multivariable regression models were developed to evaluate the association of TAVR timing on outcomes. The primary end point was in-hospital mortality whereas perioperative complications including acute kidney injury and hospitalization costs were secondarily considered. ResultsOf an estimated 5843 patients, 843 (14.4%) were Concomitant and 745 (12.7%) and 4255 (72.8%) were Early-Staged and Late-Staged, respectively. Although age and TAVR access were similar, Concomitant had a lower proportion of chronic kidney disease and more commonly underwent single-vessel PCI. Staged showed similar risk-adjusted mortality but greater odds of acute kidney injury (Early-Staged adjusted odds ratio: 2.68; 95% CI, 1.57-4.55 and Late-Staged: 1.97; 95% CI, 1.29-2.99) compared with Concomitant. Although post-TAVR hospitalization duration was similar, total length of stay and costs were increased in Staged. ConclusionsConcomitant PCI/TAVR was associated with similar rates of in-hospital mortality but reduced rates of acute kidney injury and lower resource utilization. While evaluating patient-specific factors, concomitant PCI/TAVR might be reasonable in select individuals.

Impact of Chronic Lymphocytic Leukemia on Outcomes and Readmissions After Cardiac Operations

BackgroundOutcomes of cardiac operations in patients with chronic lymphocytic leukemia (CLL) have been examined in limited series. The present study aimed to assess the impact of CLL on clinical outcomes and resource utilization after cardiac operations in a nationally representative cohort. MethodsAll adult patients undergoing elective coronary artery bypass grafting, valve repair, or valve replacement were identified utilizing the 2010 to 2017 Nationwide Readmissions Database. Patients were stratified by history of CLL. Incidence of in-hospital mortality, perioperative complications, blood transfusions, and readmission within 90 days were examined. We subsequently performed 3:1 nearest neighbor matching between CLL and non-CLL patients for all primary and secondary outcomes of interest. ResultsOf an estimated 1,250,882 patients undergoing cardiac operations, 0.23% had a diagnosis of CLL. Among 11,237 propensity matched patients, those with CLL had similar rates of in-hospital mortality (3.8% vs 2.6%; P = .08) and perioperative complications (33.4% vs 33.6%; P = .92) compared with their non-CLL counterparts. Although the incidence of infection was comparable (8.5% vs 9.4%; P = .38), CLL patients did require blood transfusions more frequently (33.7% vs 28.4%; P = .003) than others. Furthermore, CLL patients were more likely to be readmitted with respiratory etiologies contributing significantly to rehospitalization. ConclusionsPatients with CLL generally have similar outcomes after cardiac operations but may more commonly require blood transfusion. Blood-conserving interventions may be considered in this at-risk population to improve outcomes. Furthermore, interventions to mitigate readmission deserve further exploration.

Opioid dependence and treatment outcomes among patients with burn injury

BackgroundPatients with burn injuries cause significant healthcare economic burden, often utilising extra-hospital resources, caregiving, and specialized care. MethodsWe present a retrospective cohort analysis of the hospitalized patients in the USA with a primary diagnosis of burn injury. Opioid dependence was identified using ICD-10 CM codes. The 30-day all-cause readmission rate was the main outcome while secondary outcomes were inhospital mortality rate, resource utilization which included hospital length of stay, total hospitalization costs and charges and surgical procedures for burn injury treatment as well as the most important five principal diagnoses for admission and readmission. ResultsOut of 22,348 patients included in the study, 597 had opioid dependence. Older patients (43 years, range: 38.6–47.2 years) as well as males (70.8%) were more likely to be opioid dependent. Opioid dependence was associated with higher 30-day readmission rates (aOR: 1.83, 95% confidence interval (CI): 1.30–2.57, p-value: <0.01), higher total hospitalization costs (aMD: $14,981, CI: $3820–$26,142, p-value: 0.01), total hospitalization charges (aMD: $47,078, CI: −$5093 to $89,063, p-value: 0.03), and a shorter mean length of stay (aMD: 5.13 days, CI: 2.60–7.66, p-value: <0.01). However, patients with and without opioid dependence had similar in-hospital mortality rates (aOR: 0.27, CI: 0.06–1.28, p-value: 0.10). ConclusionWe are the first to our knowledge to report the association of treatment outcomes and opioid dependence in patients hospitalized at the national level with a burn injury. We show that there were higher 30-day all-cause readmission rates and in-hospital resource utilization among patients with opioid-dependence.

Clostridioides difficile infection in patients with hematological malignancy: A multicenter study in Taiwan.

Among the individuals with hematological malignancy (HM) complicated with Clostridioides difficile infection (CDI), the variables associated with in-hospital mortality and recurrence of CDI were investigated. Including adults with HM and those without malignancy suffering from CDI from January 2015 to December 2016 in three hospitals in Taiwan. Totally 314 patients including 77 with HM and 237 patients without malignancy were included. HM patients more often had low leukocyte counts (<500cells/mL: 28.6% vs. 2.1%) than those without malignancy and more patients without malignancy had severe CDI than patients with HM (31.6% vs. 14.3%, P=.003), according to the severity score of IDSA/SHEA. Patients with HM had a higher recurrence rate of CDI (14.3%, 11/77 vs. 7.2%, 17/237; P=.07) and longer hospital stay (47.2±40.8 days vs. 33.3±37.3 days; P=.006) than those without malignancy. In the multivariate analyses for those with HM and CDI, the in-hospital mortality was associated with vancomycin-resistant Enterococcus (VRE) colonization or infection (odds ratio [OR] 7.72; P=.01), and C. difficile ribotype 078 complex infection (OR 9.22; P=.03). Moreover underlying hematological malignancy (OR 2.74; P=.04) and VRE colonization/infection (OR 2.71; P=.02) were independently associated with CDI recurrence. Patients with HM complicated with CDI were often regarded as non-severe infection, but had a similar in-hospital mortality rate as those without malignancy. CDI due to ribotype 078 complex isolates heralded a poor prognosis among HM patients.

Potassium Concentration in Initial Fluid Therapy and In-Hospital Mortality of Patients with Diabetic Ketoacidosis.

Guidelines worldwide recommend potassium replacement of 10 to 40 mmol/L in the initial fluid therapy for patients with diabetic ketoacidosis. However, evidence is lacking as to the association between infused potassium concentration and mortality. We aimed to determine the association between infused potassium concentration and in-hospital mortality. Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified inpatients admitted for treatment of diabetic ketoacidosis from July 2010 to March 2018. Patients with kidney dysfunction or serum potassium abnormalities were excluded. We evaluated the association of the potassium concentration in the total infused solutions in the first 2 days of hospitalization with 28-day in-hospital mortality using multivariable regression analysis with a cubic spline model. We also assessed the association between potassium concentration and occurrence of hyperkalemia. We identified 14 216 patients with diabetic ketoacidosis and observed 261 deaths. The quartile cut-points for potassium concentration were 7.7, 11.4, and 16.1 mmol/L. Within the range of approximately 10 to 40 mmol/L, potassium concentration was not associated with occurrence of hyperkalemia or death. Lower potassium concentrations were associated with higher 28-day in-hospital mortality; the odds ratio for patients receiving 8 mmol/L was 1.69 (95% CI, 1.03 to 2.78; reference: 20 mmol/L), and the odds ratio increased monotonically as potassium concentration decreased further. Patients receiving potassium replacement at concentrations of 10 to 40 mmol/L had similar in-hospital mortality rates, whereas lower concentrations were associated with higher mortality.

Short-Term Outcomes of Transcatheter Aortic Valve Replacement in Kidney Transplant Recipients: A Nationwide Representative Study

ABSTRACT Background: Kidney transplant is the preferred treatment for end-stage kidney disease due to a better quality of life and lower morbidity and mortality than dialysis. These patients are considered high-risk patients for surgical interventions. Transcatheter aortic valve replacement (TAVR) has been introduced as an alternative to surgical aortic valve replacement in patients at high operative risk with aortic stenosis (AS). However, the outcomes of TAVR in kidney transplant patients regarding benefits and harms have not been well-studied in nationally representative data. Methods: Patients hospitalized for TAVR between January 2012 and December 2017 were identified retrospectively in the Nationwide Readmissions Database (NRD). Patients were subdivided based on having a previous history of kidney transplant. Results: Our study included 171,011 TAVR patients, of which 0.4% had a history of functioning kidney transplant. Patients with a history of kidney transplant generally had more rates of comorbidities and were more likely to develop in-hospital hemorrhagic stroke (0.7% vs. 0.1%, P = 0.004), ischemic stroke (4.5% vs. 2%, P < 0.001), acute kidney injury (25.3% vs. 13.4%, P < 0.001), and sepsis (3.9% vs. 1.6%, P < 0.001), but showed similar in-hospital mortality rates. These findings were confirmed after adjusting for other comorbidities. Conclusion: Patients with a history of kidney transplantation experience an increased risk of adverse outcomes following TAVR compared to non-kidney transplant patients. Further attention should be directed to measures to improve such outcomes in kidney transplant patients undergoing TAVR. Abbreviations: KT: kidney transplant; KTRs: kidney transplant recipients; TAVR: transcatheter aortic valve replacement; AS: aortic stenosis; SAVR: surgical aortic valve replacement; IHS: in-hospital stroke; AKI: acute kidney injury; ESKD: end-stage kidney disease; CKD: chronic kidney disease; TCEP: transcatheter cerebral embolic protection; DSCT: dual source computed tomography; VLCV: very low contrast volume

842. Impact of Active Treatment of Carbapenem-Resistant Acinetobacter baumannii Infections in US Hospitals Between 2014 and 2019

BackgroundTreatment choices for carbapenem-resistant (CR) Acinetobacter baumannii infections are limited. We analyzed the impact of active treatment on outcomes in patients infected with CR vs carbapenem-susceptible (CS) A. baumannii.MethodsAdult patients hospitalized between January 1, 2014 and June 30, 2019 with A. baumannii infections recorded in the Premier Database were retrospectively evaluated. Outcomes including mortality, discharge status (home vs other), and readmission rates were calculated as a function of receipt of active antibiotic treatment, infection site, and CR status. Antibiotic therapy was considered active if given after the index culture and displaying in vitro susceptibility.ResultsAmong 3,500 patients with A. baumannii (CR n=1,608; CS n=1,892), 2,057 patients (58.8%) received active treatment, with a much lower proportion of CR A. baumannii patients receiving active treatment than CS patients (606 [37.7%] vs 1,451 [76.7%]). Patients without active treatment had similar rates of in-hospital mortality (14.3% vs 12.9%, P=0.25) but were less likely to be discharged to home (26.3% vs 37.0%, P< 0.001) than those that received active treatment. No association between receipt of active treatment and overall mortality or discharged status was demonstrated for CR isolates (Table 1). However, among the subset of patients with CR bloodstream infections, mortality was higher in those without active treatment compared to those with active treatment (55.1% vs 25.9%, P=0.009). Overall readmission rates due to A. baumannii were considerably higher for those who did not receive active treatment vs those who did (16.0% vs 7.5%, P< 0.001) and the same was seen by differing infection sites; primarily driven by CR patients with bloodstream, respiratory, or urine infections (Table 2).Table 1. Mortality and discharge status by active treatment and carbapenem susceptibility Table 2. Readmission due to A. baumannii by active treatment and CR status among patients discharged alive ConclusionActive antibiotic therapy was associated with improved outcomes in patients with A. baumannii infections, although perhaps not to the extent expected. Further investigation into the impact of active therapy on outcomes is warranted.DisclosuresJason M Pogue, PharmD, BCPS, BCIDP, Shionogi Inc. (Advisor or Review Panel member) Yun Zhou, MS, Shionogi Inc. (Independent Contractor) Hemanth Kanakamedala, BS, Shionogi Inc. (Independent Contractor) Bin Cai, MD, PhD, Shionogi Inc. (Employee)

Transcatheter and Surgical Aortic Valve Replacement Outcomes for Patients with Chronic Heart Failure

To determine in-hospital outcomes and assess high-risk groups among chronic heart failure (CHF) patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). A retrospective analysis of the Nationwide Inpatient Sample database from January 2012 to September 2015 was performed. Hospitals across the United States that offer TAVRs or SAVRs. Adults with a diagnosis of CHF and AS. The patients underwent either TAVR or SAVR. Totals of 5,871 and 4,008 CHF patients underwent TAVR and SAVR, respectively. TAVR patients were significantly older, more were female, and had a higher comorbidity burden. No significant differences in in-hospital mortality were noted between TAVR and SAVR. However, mean length of stay was significantly longer by 3.5 days in the SAVR group, as was the mean total cost. With the exception of complete heart block, permanent pacemaker implantation, and vascular complications, the majority of postoperative events were higher among the SAVR group. Multivariate regression analysis identified postoperative cardiac, respiratory and renal complications as significant predictors of in-hospital mortality for both groups. Additionally, age ≥75 years and vascular complications were significant predictors of mortality for patients undergoing TAVR. Among CHF patients with symptomatic AS, TAVR had similar in-hospital mortality rate compared with SAVR despite higher comorbidity burden. TAVR patients are at a lower risk of cardiovascular, respiratory, and renal complications and might lead to reduced length of hospital stay and cost. Hence, TAVR may be a safer option in this population.

Mortality, morbidity, and cardiac surgery in Injection Drug Use (IDU)-associated versus non-IDU infective endocarditis: The need to expand substance use disorder treatment and harm reduction services.

BackgroundThe addiction crisis is widespread, and unsafe injection practices among people who inject drugs (PWID) can lead to infective endocarditis.MethodsA retrospective analysis of adult patients with definite or possible infective endocarditis admitted to a tertiary care center in Portland, Maine was performed over three-year period. Our primary objective was to examine differences in demographics, health characteristics, and health service utilization between injection drug use (IDU)-associated infective endocarditis and non-IDU infective endocarditis. The association between IDU and mortality, morbidity (defined as emergency department visits within 3 months of discharge), and cardiac surgery was examined. Bivariate and multivariate analyses were performed. A subgroup descriptive analysis of PWID was also performed to better examine substance use disorder (SUD) characteristics, treatment with medication for opioid use disorder (MOUD) and health service utilization.ResultsOne-hundred and seven patients were included in the study, of which 39.2% (n = 42) had IDU-associated infective endocarditis. PWID were more likely to be homeless, uninsured, and lack a primary care provider. PWID were notably younger and had less documented comorbidities, however had similar in-hospital mortality rates (10% vs. 14%, p = 0.30), ED visits (50% vs. 54%, p = 0.70) and cardiac surgery (33% vs. 26%, p = 0.42) compared to those with non-IDU infective endocarditis. Ninety-day mortality was less among PWID (19.0% vs. 36.9%, p = 0.05). IDU was not associated with morbidity (adjusted odds ratio (AOR) 0.73, 95% CI 0.18–3.36), 90-day mortality (AOR 0.72, 95% CI 0.17–3.01), or cardiac surgery (AOR 0.15, 95% CI 0.03–0.69). Ninety-day mortality among PWID who received MOUD was lower (3% vs 15%, p = 0.45), as were ED visits (10% vs. 41%, p = 0.42) compared to those who did not receive MOUD.ConclusionsOur results highlight existing differences in health characteristics and social determinants of health in people with IDU-associated versus non-IDU infective endocarditis. PWID had less comorbidities and were significantly younger than those with non-IDU infective endocarditis and yet still had similar rates of cardiac surgery, ED visits, and in-hospital mortality. These findings emphasize the need to deliver comprehensive health services, particularly MOUD and other harm reduction services, to this marginalized population.

Impact of type 2 diabetes mellitus on short- and long-term mortality after coronary artery bypass surgery

BackgroundType 2 diabetes mellitus (DM) is a frequent co-morbidity among patients undergoing coronary artery bypass grafting (CABG) surgery. The aim of this study was to evaluate the impact of DM on the early- and long-term outcomes of patients who underwent isolated CABG.MethodsWe performed an observational cohort study in a large tertiary medical center over a period of 11 years. All data from patients who had undergone isolated CABG surgery between 2004 and 2014 were obtained from our departmental database. The study population included 2766 patients who were divided into two groups: Group I (1553 non-diabetic patients), and Group II (1213 patients suffering from type 2 DM). Group II patients were then divided into two subgroups: subgroup IIA (981 patients treated with oral antihyperglycemic medications) and subgroup IIB (232 insulin-treated patients with or without additional oral antihyperglycemic drugs). In-hospital, 1-, 3-, 5- and 10-year mortality outcome variables were evaluated. Mean follow-up was 97 ± 41 months.ResultsIn-hospital mortality was similar between Group I and Group II patients (1.87% vs. 2.31%, p = 0.422) and between the subgroups IIA and IIB (2.14% vs. 3.02%, p = 0.464). Long-term mortality (1, 3, 5 and 10 years) was higher in Group II (DM type 2) compared with Group I (non-diabetic patients) (5.3% vs. 3.6%, p = 0.038; 9.3% vs. 5.6%, p < 0.001; 15.3% vs. 9.3%, p < 0.001 and 47.3% vs. 29.6% p < 0.001). Kaplan–Meier analysis demonstrated that all-cause mortality was higher in Group II compared with Group I (p < 0.001) and in subgroup IIB compared with subgroup IIA (p = 0.001). Multivariable analysis showed that DM increased the mortality hazard by twofold, and among diabetic patients, insulin treatment increased the mortality hazard by twofold.ConclusionsDiabetic and non-diabetic patients have similar in-hospital mortality rates. Survival rates of diabetic patients start to deteriorate 3 year after surgery. Type 2 DM is an independent predictor for long-term mortality after isolated CABG surgery. Mortality is even higher when the diabetes treatment strategy included insulin.

NATIONAL OUTCOMES OF STATUS ASTHMATICUS AMONG THE ELDERLY

SESSION TITLE: Critical Care 2 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Asthma is an unrecognized entity in the elderly with a prevalence of 13%. Acute asthma exacerbation (AAE) in this population presents a significant risk of morbidity and mortality. Status asthmaticus (SA) represents the most severe presentation of this disease, in which asthma attacks occur continuously without remission. Outcomes of AAE and SA in the elderly are not well studied. We sought to investigate the impact of SA among elderly patients in a large national dataset. METHODS: The National Inpatient Sample (NIS) was investigated for geriatric patients admitted with SA and AAE between 2009 and 2014. Demographic and clinical characteristics, including age, sex, race, income groups, comorbidity, and hospital types were compared between groups. We then compared across clinical outcomes of interest, including use of non-invasive mechanical ventilation (NIMV), invasive mechanical ventilation (IMV), prolonged IMV > 96 hours, in-hospital mortality and discharge to home. All estimates utilized appropriate complex survey methods, such that estimates were nationally representative. Significant differences between groups were tested using Rao-Scott Chi-Square. RESULTS: There were 475,770 weighted discharges for asthma exacerbation over the study period, of which 15,318 (3.2%) were SA. Overall, female sex (72.3%), was predominant in our cohort with multiple comorbidities (78.3%), and highest prevalence in the winter (29.3%) and spring (27.0%) months. Patients with SA tended to be slightly younger than those with AAE (AAE mean 75.9 y vs SA mean 74.7 y, p<0.0001) and had a longer length of stay (AAE mean 4.6 d vs SA 5.5 d, p<0.0001). Although there were similar rates of NIMV use (AAE 4.5% vs SA 5.4%, p = 0.05), there was a more than two-fold difference in the rate of IMV (AAE 1.5% vs SA 4.4%, p<0.0001). Despite this, among patient who did receive IMV, there were no significant differences in prolonged IMV >96 hours (AAE 34.3% of IMV vs SA 31.5% of IMV, p=0.52). Furthermore, though there were similar rates of in-hospital mortality in patients admitted with SA (AAE 0.9% vs SA 1.2%, p = 0.06), SA patients were significantly more likely to be discharged to home without services (AAE 65.9% vs SA 71.4%, p <0.0001). CONCLUSIONS: Patients admitted with SA were more likely to receive IMV than their AAE counterparts, yet were more frequently discharged home without services. SA in the elderly is associated with a high mortality and warrants aggressive interventions. Clinicians should be aware and have a low threshold for ventilator support when appropriate to avoid adverse clinical outcomes. CLINICAL IMPLICATIONS: There is need to keep a low threshold for ventilator support, NIMV or IMV in the elderly with SA. DISCLOSURES: No relevant relationships by Raymonde Jean, source=Web Response No relevant relationships by Raymond Jean, source=Web Response No relevant relationships by Sathish Pondaiah, source=Web Response No relevant relationships by Bertin Salguero, source=Web Response No relevant relationships by Fernando Vazquez de Lara, source=Web Response

Post-operative Bleeding Increases the Rate of Right Ventricular Failure and In-Hospital Mortality after LVAD Implantation

Purpose Surgical bleeding in the immediate post-operative period presents a frequent challenge in the management of LVAD recipients. We hypothesized that implementing an aggressive approach to surgical hemostasis would reduce the rate of early mortality. Methods We conducted a single-center retrospective review of 78 patients who underwent LVAD implantation between 9/13/11 and 8/24/17. Logistic regressions were utilized to estimate the odds ratio for RVAD requirement and in-hospital mortality based on risk factors of six-hour chest tube output and return to operating room for bleeding. Chest tube output of greater than 600 cc in the first six hours was considered to be significant. Results When comparing chest tube outputs in the first six hours, there were no significant differences in age, gender, heart failure etiology, or device type in patients with >600 cc and those with lower outputs. Greater than 600 cc chest tube output in the first six hours was an independent predictor for RVAD requirement (15.2% vs. 2.3%, p=0.04) and in-hospital mortality (24.2% vs. 4.7%, p=0.012) than those with lower outputs. Patients who returned to the operating room for bleeding complications experienced a similar in-hospital mortality rate (17.6% vs. 9.3%, p=0.28) but had a higher RVAD requirement (14.7% vs. 2.3%, p=0.04). Multivariate analysis showed a statistical significance for in-patient mortality in patients with chest tube output >600 cc in the first 6 hours (p = 0.013). There was a close correlation between the amount of chest tube output during the first six hours and the risk of in-hospital mortality ( Figure 2 ). Conclusion Minimizing the degree of post-operative bleeding after LVAD surgery may result in a reduced rate of right ventricular failure and in-hospital mortality. These findings suggest that efforts should be undertaken to identify surgical strategies for achieving improved hemostasis at the time of implantation.

A lower eicosapentaenoic acid/arachidonic acid ratio is associated with in-hospital fatal arrhythmic events in patients with acute myocardial infarction: a J-MINUET substudy.

The ratio of serum eicosapentaenoic acid (EPA) to arachidonic acid (AA) is significantly associated with long-term clinical outcomes in patients with acute myocardial infarction (AMI). However, it has not been conclusively demonstrated that higher serum EPA/AA ratio fares better clinical outcomes in the early phase of AMI. The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry conducted in 28 Japanese medical institutions between July 2012 and March 2014. We enrolled 3,283 consecutive AMI patients who were admitted to participating institutions within 48h of symptom onset. A serum EPA/AA ratio was available for 629 of these patients. The endpoints were in-hospital mortality and major adverse cardiac events (MACE), defined as a composite of all cause death, cardiac failure, ventricular tachycardia (VT) and/or ventricular fibrillation (VF) and bleeding during hospitalization. Although similar rates of in-hospital mortality, cardiac failure, bleeding, and MACE were found in the lower serum EPA/AA group and higher serum EPA/AA group, the incidence of VT/VF during hospitalization was significantly higher in the low ratio group (p=0.008). Receiver operating characteristic curve analysis showed that an EPA/AA ratio <0.35 could predict the incidence of VT/VF with 100% sensitivity and 64.0% specificity. A lower serum EPA/AA ratio was associated with a higher frequency of fatal arrhythmic events in the early phase of AMI.

Crohnʼs Disease Is Associated with Increased Morbidity and Resource Utilization in Patients Hospitalized with Acute Pancreatitis: Results of a Nationwide Analysis

Introduction: Crohn's disease (CD) is associated with pancreatitis due to drug toxicity, duodenal disease, biliary involvement or autoimmune disease. To date, the impact of CD on mortality and other outcomes among patients with Acute Pancreatitis (AP) has not been investigated. Therefore, the aim of this study is to explore the impact of past or current CD on mortality, morbidity and resource utilization among patients hospitalized for AP. Methods: This was a retrospective cohort study using the 2013 National Inpatient Sample, the largest publically available inpatient database in the United States. All patients with an ICD-9 CM code for a principal diagnosis of AP were included. There were no exclusion criteria. The primary outcome was in-hospital mortality. Secondary outcomes were morbidity measured by intensive care unit (ICU) admission, shock and multi-organ failure; resource utilization measured by abdominal CT scan, abdominal ultrasound (US), total parenteral nutrition (TPN) use, length of hospital stay (LOS) and total hospitalization charges. Patients were classified as having CD or not having CD using ICD-9 CM codes. Using multivariate regression analysis, odds ratios and means were adjusted for age, sex, race, median income in the patient's zip code, Charlson Comorbidity Index, hospital region, urban location, size and teaching status. Results: 274,775 patients with AP were included in the study, 2,255 (0.8%) of whom had CD. Mean age was 51 years and 47% were female. The overall in-hospital mortality rate was 0.8% (0.2% in patients with CD). Table 1 shows all adjusted odds ratios, adjusted means and p-values. On multivariate analysis, patients with CD had similar in-hospital mortality rates compared to patients without CD (OR:0.43, 95%CI:0.06-3.12, p=0.41). Looking at morbidity, patients with CD displayed higher odds of shock, malnutrition and TPN use. Resource utilization did not differ between groups. Patients with CD had significantly longer hospital lengths of stay but not total hospitalization charges when compared to patients without CD.Table 1: Adjusted odds ratios, means and p-values for the evaluated parameters in patients with acute pancreatitis and CD compared to patients with no CD.Conclusion: CD is not associated with increased mortality in patients hospitalized with AP. Importantly, CD is associated with increased morbidity reflected by higher odds of shock and malnutrition. Furthermore, CD in patients with AP is associated with longer LOS when compared to patients without CD.

Temporal trends in nitrate utilization for acute heart failure in elderly emergency patients: A single-centre observational study

We previously conducted a pilot study that reported the safety of isosorbide dinitrate boluses for elderly emergency patients with acute heart failure syndrome. To assess the temporal trend in the rate of elderly patients treated with isosorbide dinitrate, and to evaluate subsequent outcome differences. This was a single-centre study. We compared patients aged>75 years who attended the emergency department with a primary diagnosis of acute pulmonary oedema in the years 2007 and 2014. The primary endpoint was the rate of patients who received isosorbide dinitrate boluses in the emergency department. Secondary endpoints included in-hospital mortality, need for intensive care and length of stay. We analysed 368 charts, 232 from patients included in 2014 (63%) and 136 in 2007 (37%). The mean age was 85±6 years in both groups. There was a significant rise in the rate of patients treated with isosorbide dinitrate between 2007 and 2014: 97 patients (42%) in 2014 vs. 24 patients (18%) in 2007 (P<0.01). Comparing the two periods, we report similar in-hospital mortality rates (8% vs. 11%; P=0.5), rates of admission to the intensive care unit (13% vs. 17%; P=0.3) and lengths of stay (10 days in both groups). We observed a significant rise in the rate of elderly patients treated with isosorbide dinitrate boluses for acute heart failure. However, we did not observe any significant improvement in outcomes.

Outcomes of unilateral and bilateral total knee arthroplasty in 238,373 patients

Background and purpose — There is no consensus about the outcome of simultaneous vs. staged bilateral total knee arthroplasty (TKA). We examined this issue by analyzing 238,373 patients.Patients and methods — Demographic, clinical, and outcome data were evaluated for TKA patients (unilateral: 206,771; simultaneous bilateral: 6,349; staged bilateral: 25,253) from the Canadian Hospital Morbidity Database for fiscal years 2006–2007 to 2012–2013. Outcomes were adjusted for age, sex, comorbidities, and hospital TKA volume.Results — Simultaneous bilateral TKA patients were younger than staged bilateral TKA patients (median 64 years vs. 66 years), were more likely to be male (41% vs. 39%), and had a lower frequency of having ≥1 comorbid condition (2.9% vs. 4.2%). They also had a higher frequency of blood transfusions (41% vs. 19%), a shorter median length of stay (6 days vs. 8 days), a higher frequency of transfer to a rehabilitation facility (46% vs. 9%), and a lower frequency of knee infection (0.5% vs. 0.9%) than staged bilateral TKA patients, but they had higher rate of cardiac complications within 90 days (2.0% vs. 1.7%). Simultaneous patients had higher in-hospital mortality compared to the second TKA in staged patients (0.16% vs. 0.06%), but they had similar rates of in-hospital mortality compared to unilateral patients (0.16% vs. 0.14%). The cumulative 3-year revision rate was highest in the unilateral group (2.3%), but it was similar in the staged and simultaneous bilateral groups (1.4%).Interpretation — We found important differences between the outcomes of simultaneous and staged bilateral TKA. Further clarification of outcomes would be best determined in an adequately powered randomized trial, which would remove the selection bias inherent in this retrospective study design.

Associations of Volume and Thyroidectomy Outcomes: A Nationwide Study with Systematic Review and Meta-Analysis.

This study explored how different hospital volumes and surgeon volumes affect thyroidectomy outcomes in terms of length of stay (LOS), costs, and in-hospital mortality. MEDLINE and EMBASE databases. This study retrospectively analyzed a cohort of 125,037 thyroidectomy patients treated at Taiwan hospitals from 1996 to 2010. Relationships between hospital/surgeon volume and patient outcomes were retrospectively analyzed by propensity score matching. In conjunction with the retrospective study, a systematic review and meta-analysis of the relevant literature also were performed. The mean LOS for all thyroidectomies performed during the study period was 3.3 days, and the mean cost was $1193.5. Both high-volume hospitals and high-volume surgeons were associated with significantly shorter LOS and lower costs compared with their low-volume counterparts (P < .001). Different volume groups had similar in-hospital mortality rates. The meta-analysis results consistently showed that the benefits of high-volume hospitals/surgeons are reduced LOS and costs. However, low in-hospital mortality rates were associated with high-volume surgeons but not with high-volume hospitals. This meta-analysis showed that patients who received thyroidectomies performed by high-volume hospitals and surgeons had shorter LOS and lower costs compared with those treated by low-volume hospitals and surgeons. In addition, in-hospital survival rates were better in patients treated by high-volume surgeons. Further research is needed to define the learning curve for thyroidectomy and to clarify how hospital volume and surgeon volume affect its success rate.

Abstract 15788: Percutaneous and Surgical Carotid Artery Revascularization in Patients With Moderate and Severe (Stage 3 and 4) Chronic Kidney Disease: Insights of the Healthcare Cost and Utilization Project’s National Inpatient Sample

Background: Carotid artery stenting (CAS) has evolved into an alternative modality for the treatment of symptomatic and asymptomatic high-grade internal carotid artery stenosis, particularly in patients considered to be at a high surgical risk for carotid endarterectomy (CEA). Hypothesis: There is limited data on the outcomes of patients with moderate and severe chronic kidney disease (CKD) (GFR=15-59 mL/min/1.73m 2 ) (Stage 3 and 4) undergoing CEA or CAS. Methods: The Healthcare Cost and Utilization Project’s National Inpatient Sample was screened for hospital admissions of patients undergoing CAS and CEA from 2003-2012. Clinical characteristics and outcomes were identified in patients with stage 3 and 4 CKD. The primary outcome of interest was in-hospital major adverse cardiac and cerebrovascular events (MACCE) defined as the composite of in-hospital death, acute myocardial infarction (AMI) and acute cerebrovascular accident (CVA). Results: Our study population consisted of 3,608 patients that underwent CEA and 746 patients that underwent CAS. Patients undergoing CAS had significantly higher rates of coronary artery disease and peripheral vascular disease with similar rates of hypertension, diabetes and hyperlipidemia. There was a higher rate of in-hospital MACCE in patients undergoing CAS compared with patients that underwent CEA, mainly driven by a higher rate of in-hospital strokes (Fig. 1). AMI and mortality rates were similar in both groups. In a multivariable analysis, CAS (OR 1.52, 95% CI 1.25-1.84) was independently predictive of MACCE. Conclusions: In patients with moderate and severe CKD, CAS was associated with similar rates of in-hospital mortality and AMI rates but higher rates of stroke when compared with CEA.

MP9-18 ANTICIPATING THE IMPACT OF ACCOUNTABLE CARE ORGANIZATIONS ON THE COST AND QUALITY OF UROLOGIC CANCER CARE

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes II1 Apr 2015MP9-18 ANTICIPATING THE IMPACT OF ACCOUNTABLE CARE ORGANIZATIONS ON THE COST AND QUALITY OF UROLOGIC CANCER CARE Lindsey Herrel, Scott Hawken, Chandy Ellimoottil, Zachary Montgomery, Zaojun Ye, and David Miller Lindsey HerrelLindsey Herrel More articles by this author , Scott HawkenScott Hawken More articles by this author , Chandy EllimoottilChandy Ellimoottil More articles by this author , Zachary MontgomeryZachary Montgomery More articles by this author , Zaojun YeZaojun Ye More articles by this author , and David MillerDavid Miller More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.378AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Many believe that Accountable Care Organizations (ACOs) will lead to higher quality and lower cost healthcare, including for specialty care like urology. In this context, we examined baseline outcomes and costs of inpatient urologic cancer surgery at hospitals that joined Medicare ACO programs compared with similar hospitals that are not participating. METHODS We used the Nationwide Inpatient Sample and American Hospital Association Survey to conduct a retrospective cohort study of patients undergoing inpatient urologic cancer surgery at ACO participating hospitals and non-ACO participating hospitals from 2007 through 2011. Hospitals participating in an ACO were identified from the Center for Medicare and Medicaid Services website as of February 2014. Propensity matching based on hospital structural characteristics was performed to identify non-participating hospitals from states with <6% of lives covered in an ACO. For three urologic cancer operations (prostatectomy, nephrectomy, cystectomy) we fit multivariable models to compare in-hospital mortality, prolonged length of stay (LOS, >90th percentile), and total hospital costs for patients treated at ACO and non-ACO participating hospitals. RESULTS Propensity matching identified 352 non-ACO hospitals to compare with 176 ACO participating hospitals. In multivariable analyses, neither mortality nor prolonged LOS differed according to ACO participation. Total hospitals costs were also similar for patients undergoing prostatectomy, nephrectomy and cystectomy at ACO participant versus non-participant hospitals (Figure). CONCLUSIONS Prior to implementation of Accountable Care Organizations, hospitals that now participate in these programs had similar rates of in-hospital mortality, prolonged LOS, and cost for inpatient urologic cancer care compared with hospitals that are not participating. Future studies will determine whether ACO participation meets the high expectations for higher quality and lower cost care in urology and other specialities. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e108-e109 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lindsey Herrel More articles by this author Scott Hawken More articles by this author Chandy Ellimoottil More articles by this author Zachary Montgomery More articles by this author Zaojun Ye More articles by this author David Miller More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Abstract W P50: The Influence of Obesity on Outcomes After Intravenous Thrombolysis for Acute Ischemic Stroke

Background: Current ASA guidelines do not recommend increasing the dose of intravenous tissue plasminogen activator (IV rt-PA) for acute ischemic stroke patients weighing &gt;100 kg. However, the consequences of such potential under-dosing may mean that it is less effective or even less harmful. Objective: To determine the relationship between obesity and clinical outcomes among acute ischemic stroke patients receiving IV rt-PA. Methods: We identified patients who received IV recombinant tissue plasminogen activator (rt-PA) at 35 hospitals participating in the Michigan Coverdell Acute Stroke Registry from January2009 to December 2011. All ischemic strokes treated within 4.5 hours with non-missing BMI data were included in the analysis. Patient BMI was dichotomized as obese (BMI ≥30) or non-obese (BMI &lt;30). Outcome measures included symptomatic intracerebral hemorrhage (sICH), in-hospital death, complications, length of stay (LOS) and discharge to home. The independent effects of obesity on outcomes were analyzed using logistic regression analysis with adjustment for age, gender, race and medical history. Results: Of 698 AIS patients who received IV rt-PA 536 (76.7%) had information on BMI recorded. Among those, 263 (37.7%) were obese. Compared to non-obese patients, obese patients were more likely to be women (57.8% vs. 44.6% p=0.0007), be younger (mean age 64.0 vs. 69.7 p&lt;0.0001), and have hypertension and diabetes mellitus. Obese patients had longer LOS (mean 7.0 vs. 5.8 days, p=0.009) and were more likely to develop urinary tract infections (6.3 % vs. 11.3 %; p=0.009). In a multivariate regression model adjusting for age, gender, race medical comorbidities, obese to non-obese patients rates of sICH (OR, 95% CI 1.2 (0.47- 3.2), p= 0.68, death [OR, 95% CI 1.2 (0.56- 2.8),p=0.60] and discharge to home [OR, 95% CI 1.0 (0.69- 1.5), p=0.89)were all similar. Conclusion: Obese patients receiving IV t-PA treatment for acute ischemic stroke had similar rates of in-hospital mortality, discharge to home and sICH, but they had longer LOS and rates of UTI. Future studies should be undertaken to determine if the clinical efficacy of tPA is affected by under-dosing focusing on both radiographic recanalization rates and functional clinical outcomes.