Trends In In-hospital Mortality Research Articles

Health disparities experienced by Black Americans with multiple myeloma in the United States: A population-based study.

e18512 Background: Multiple Myeloma (MM) is the most common hematologic malignancy in Black Americans. Incidence and death rates for MM in Black Americans are more than double those in Whites. Our study aimed to evaluate trends of all cause in-hospital mortality among Black Americans with MM and to investigate characteristics of MM-related hospitalizations. Methods: We conducted a retrospective cross-sectional study of hospitalizations in adult patients with MM during 2008-2017 using the National Inpatient Sample (NIS), the largest all-payer inpatient care database in the US. We used joinpoint regression to assess temporal trends in the national incidence of in-hospital death. We conducted adjusted survey logistic regression to generate adjusted odds ratios to measure the likelihood of in-hospital death among MM related hospitalizations. Results: Admissions related to MM constituted 0.32% of all hospitalizations in the study period (913,967 out of 285,876,821). The prevalence of MM related hospitalizations was higher in Black Americans when compared with Whites (476.0 vs 305.6 per 100,000 hospitalizations, p <0.01). In-hospital mortality with MM was higher in older patients, males, those belonging to lowest zip code quartile, and who self-paid for their treatment. Average Annual Percent Change (AAPC) showed a statistically significant decline of in-hospital mortality among all MM patients except Black Americans who had the highest inpatient mortality in 2016 and 2017. Black Americans received less autologous stem cell transplantation (ASCT) (2.8% vs. 3.8%, p <0.01), more blood product transfusions (23.0% vs. 21.1%, p <0.01), less palliative care consultation (4.0% vs. 4.6%, p <0.01), less chemotherapy (10.8% vs. 11.2%, p <0.01), and more intensive care utilization (5.3% vs. 4.3%, p <0.01), when compared with Whites. Adjusted association between race/ethnicity and various outcomes confirmed observed differences [Table]. Conclusions: Black Americans with MM had the slowest improvement and highest inpatient mortality in recent years. Data suggests higher disease burden, more frequent hospitalizations, delay in accessing care and lower utilization of supportive care measures compared with White MM patients. Data highlight disparities in MM care for Black Americans necessitating a clarion call for urgent changes in health care systems.[Table: see text]

Trends in risk stratification, in-hospital management and mortality of patients with acute pulmonary embolism: an analysis from the China pUlmonary thromboembolism REgistry Study (CURES).

Similar trends of management and in-hospital mortality of acute pulmonary embolism (PE) have been reported in European and American populations. However, these tendencies are not clear in Asian countries. We retrospectively analysed the trends of risk stratification, management and in-hospital mortality for patients with acute PE through a multicentre registry in China (CURES).Adult patients with acute symptomatic PE were included between 2009 and 2015. Trends in disease diagnosis, treatment and death in hospital were fully analysed. Risk stratification was retrospectively classified by haemodynamic status and the simplified Pulmonary Embolism Severity Index (sPESI) score according to the 2014 European Society of Cardiology/European Respiratory Society guidelines.Among 7438 patients, the proportions with high (haemodynamic instability), intermediate (sPESI≥1) and low (sPESI=0) risk were 4.2%, 67.1% and 28.7%, respectively. Computed tomographic pulmonary angiography was the most widely used diagnostic approach (87.6%) and anticoagulation was the most frequently adopted initial therapy (83.7%). Between 2009 and 2015, a significant decline was observed for all-cause mortality (from 3.1% to 1.3%, adjusted pfor trend=0.0003), with a concomitant reduction in the use of initial systemic thrombolysis (from 14.8% to 5.0%, pfor trend<0.0001). The common predictors for all-cause mortality shared by haemodynamically stable and unstable patients were co-existing cancer, older age and impaired renal function.The considerable reduction of mortality over the years was accompanied by changes in initial treatment. These findings highlight the importance of risk stratification-guided management throughout the nation.

Trends in Patient Characteristics and COVID-19 In-Hospital Mortality in the United States During the COVID-19 Pandemic

In-hospital mortality rates from COVID-19 are high but appear to be decreasing for selected locations in the United States. It is not known whether this is because of changes in the characteristics of patients being admitted. To describe changing in-hospital mortality rates over time after accounting for individual patient characteristics. This was a retrospective cohort study of 20 736 adults with a diagnosis of COVID-19 who were included in the US American Heart Association COVID-19 Cardiovascular Disease Registry and admitted to 107 acute care hospitals in 31 states from March through November 2020. A multiple mixed-effects logistic regression was then used to estimate the odds of in-hospital death adjusted for patient age, sex, body mass index, and medical history as well as vital signs, use of supplemental oxygen, presence of pulmonary infiltrates at admission, and hospital site. In-hospital death adjusted for exposures for 4 periods in 2020. The registry included 20 736 patients hospitalized with COVID-19 from March through November 2020 (9524 women [45.9%]; mean [SD] age, 61.2 [17.9] years); 3271 patients (15.8%) died in the hospital. Mortality rates were 19.1% in March and April, 11.9% in May and June, 11.0% in July and August, and 10.8% in September through November. Compared with March and April, the adjusted odds ratios for in-hospital death were significantly lower in May and June (odds ratio, 0.66; 95% CI, 0.58-0.76; P < .001), July and August (odds ratio, 0.58; 95% CI, 0.49-0.69; P < .001), and September through November (odds ratio, 0.59; 95% CI, 0.47-0.73). In this cohort study, high rates of in-hospital COVID-19 mortality among registry patients in March and April 2020 decreased by more than one-third by June and remained near that rate through November. This difference in mortality rates between the months of March and April and later months persisted even after adjusting for age, sex, medical history, and COVID-19 disease severity and did not appear to be associated with changes in the characteristics of patients being admitted.

Mortality Among US Patients Hospitalized With SARS-CoV-2 Infection in 2020

Mortality is an important measure of the severity of a pandemic. This study aimed to understand how mortality by age of hospitalized patients who were tested for SARS-CoV-2 has changed over time. To evaluate trends in in-hospital mortality among patients who tested positive for SARS-CoV-2. This retrospective cohort study included patients who were hospitalized for at least 1 day at 1 of 209 US acute care hospitals of variable size, in urban and rural areas, between March 1 and November 21, 2020. Eligible patients had a SARS-CoV-2 polymerase chain reaction (PCR) or antigen test within 7 days of admission or during hospitalization, and a record of discharge or in-hospital death. SARS-CoV-2 positivity. SARS-CoV-2 infection was defined as a positive SARS-CoV-2 PCR or antigen test within 7 days before admission or during hospitalization. Mortality was extracted from electronically available data. Among 503 409 admitted patients, 42 604 (8.5%) had SARS-CoV-2-positive tests. Of those with SARS-CoV-2-positive tests, 21 592 (50.7%) were male patients. Hospital admissions among patients with SARS-CoV-2-positive tests were highest in the group aged 65 years or older (19 929 [46.8%]), followed by those aged 50 to 64 years (11 602 [27.2%]) and 18 to 49 years (10 619 [24.9%]). Hospital admissions among patients 18 to 49 years of age increased from 1099 of 5319 (20.7%) in April to 1266 of 4184 (30.3%) in June and 2156 of 7280 (29.6%) in July, briefly exceeding those in the group 50 to 64 years of age (June: 1194 of 4184 [28.5%]; 2039 of 7280 [28.0%]). Patients with SARS-CoV-2-positive tests had higher in-hospital mortality than patients with SARS-CoV-2-negative tests (4705 [11.0%] vs 11 707 of 460 805 [2.5%]; P < .001). In-hospital mortality rates increased with increasing age for both patients with SARS-CoV-2-negative tests and SARS-CoV-2-positive tests. In patients with SARS-CoV-2-negative tests, mortality increased from 45 of 11 255 (0.4%) in those younger than 18 years to 4812 of 107 394 (4.5%) in those older than 75 years. In patients with SARS-CoV-2-positive tests, mortality increased from 1 of 454 (0.2%) of those younger than 18 years to 2149 of 10 287 (20.9%) in those older than 75 years. In-hospital mortality rates among patients with SARS-CoV-2-negative tests were similar for male and female patients (6273 of 209 086 [3.0%] vs 5538 of 251 719 [2.2%]) but higher mortality was observed among male patients with SARS-CoV-2-positive tests (2700 of 21 592 [12.5%]) compared with female patients with SARS-CoV-2-positive tests (2016 of 21 012 [9.60%]). Overall, in-hospital mortality increased from March to April (63 of 597 [10.6%] to 1047 of 5319 [19.7%]), then decreased significantly to November (499 of 5350 [9.3%]; P = .04), with significant decreases in the oldest age groups (50-64 years: 197 of 1542 [12.8%] to 73 of 1341 [5.4%]; P = .02; 65-75 years: 269 of 1182 [22.8%] to 137 of 1332 [10.3%]; P = .006; >75 years: 535 of 1479 [36.2%] to 262 of 1505 [17.4%]; P = .03). This nationally representative study supported the findings of smaller, regional studies and found that in-hospital mortality declined across all age groups during the period evaluated. Reductions were unlikely because of a higher proportion of younger patients with lower in-hospital mortality in the later period.

Development of the Madrid Stroke Programme: Milestones and Changes in Stroke Trends and Mortality from 1997 to 2017

Introduction: Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. Methods: Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. Results: Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. Conclusions: Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

Age- and Severity-Related In-Hospital Mortality Trends and Risks of Severe Traumatic Brain Injury in Japan: A Nationwide 10-Year Retrospective Study.

Traumatic brain injury (TBI) is the major cause of mortality and morbidity in severely-injured patients worldwide. This retrospective nationwide study aimed to evaluate the age- and severity-related in-hospital mortality trends and mortality risks of patients with severe TBI from 2009 to 2018 to establish effective injury prevention measures. We retrieved information from the Japan Trauma Data Bank dataset between 2009 and 2018. The inclusion criteria for this study were patients with severe TBI defined as those with an Injury Severity Score ≥ 16 and TBI. In total, 31,953 patients with severe TBI (32.6%) were included. There were significant age-related differences in characteristics, mortality trend, and mortality risk in patients with severe TBI. The in-hospital mortality trend of all patients with severe TBI significantly decreased but did not improve for patients aged ≤ 5 years and with a Glasgow Coma Scale (GCS) score between 3 and 8. Severe TBI, age ≥ 65 years, fall from height, GCS score 3–8, and urgent blood transfusion need were associated with a higher mortality risk, and mortality risk did not decrease after 2013. Physicians should consider specific strategies when treating patients with any of these risk factors to reduce severe TBI mortality.

Gender differences, outcomes and trends among nonagenarian with atrial fibrillation: insight from National Inpatient Sample database.

BACKGROUNDNonagenarians (NG), individuals aged ≥ 90 years, constitute an increasing proportion of hospitalizations presenting with atrial fibrillation (AF). However, not much is known about demographics, clinical outcomes, and trends of hospitalizations. Therefore, we analyzed data about hospitalizations and clinical outcomes among NGs with AF over ten years from 2005 to 2014 using a publically available database, the National Inpatient Sample.METHODSAll hospitalizations and major outcomes of subjects ≥ 90 years with a primary diagnosis of AF (ICD-9-CM code 427.31) over a ten-year period were assessed in this study by multivariate logistic regression analysis.RESULTSThere were more females than males (176,268 females, 51,384 males) in this analysis. The number of hospitalizations for AF among NG increased by 50% (17,295 in 2005 to 25,830 in 2014). Males were more likely to undergo cardioversion (6.14% of males vs. 5.06% of females, P < 0.0001). Over this period, in-hospital mortality declined from 3.21% in 2005 to 2.38% in 2014 ( P = 0.0041), with higher in-hospital mortality in males (3.23% in males vs. 2.76% in females, P = 0.0138), mean length of hospitalization decreased from 4.53 days to 4.13 days (P < 0.0001), the prevalence of congestive heart failure fell from 0.48% to 0.23% ( P = 0.0257), and the use of anticoagulation increased from 6.09% to 14.54% (P < 0.0001). In a multivariate analysis, hospital admission on the weekend, Elixhauser comorbidity index, CHA 2DS2VASc score, acute respiratory failure, and the length of hospital stay were associated with a higher risk of in-hospital mortality. CONCLUSIONSFrom 2005 to 2014, AF-related hospitalizations among NGs increased, more so in in females population, mortality trends improved, rates of anticoagulation increased, and cardioversions increased. Despite the decreasing trend of in-hospital mortality since 2005, the relatively high mortality rate in males warrants further studies.

Contemporary Trends in Hospital Admissions and Outcomes in Patients With Critical Limb Ischemia: An Analysis From the National Inpatient Sample Database.

Critical limb ischemia (CLI) morbidity and mortality rates have historically been disproportionately higher than for other atherosclerotic diseases, however, recent trends have not been reported. In patients admitted with CLI, we aimed to examine trends in in-hospital mortality, major amputations, length of stay, and cost of hospitalizations overall and stratified by type of revascularization procedures. Using 2011 to 2017 National Inpatient Sample data, we identified CLI-related admissions based on International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification codes. Primary outcomes of interest were in-hospital mortality and major amputations. Secondary outcomes were the length of stay and cost of hospitalization. We stratified outcomes based on endovascular or open surgical interventions. We also performed hierarchical multivariable regression analyses of outcomes based on age, sex, race, hospital size, type, and location. We identified 2 643 087 CLI-related admissions between 2011 and 2017. CLI admissions increased from 0.9% to 1.4% Ptrend<0.0001 as well as overall peripheral artery disease admissions (4.5%-8.9%, Ptrend<0.0001). In-hospital mortality for the entire CLI cohort decreased from 3.3% to 2.7%, Ptrend<0.0001, and major amputations decreased from 10.9% to 7%, Ptrend<0.0001. A decline was also noted for the length of stay from 5.7 (3.1-10.1) to 5.4 (3.0-9.2) days (Ptrend<0.0001), whereas admission costs increased from USD $11 791 ($6676-$21 712) to $12 597 ($7248-$22 748; Ptrend<0.0001). Endovascular interventions increased (Ptrend<0.0001) against a decline in surgical interventions (Ptrend<0.0001). Black race, female sex, and age ≥60 years were associated with higher in-hospital mortality, whereas Black race, male sex, and age<60 years were associated with higher major amputations. A relatively small decrease in absolute numbers for mortality and major amputations were observed against a backdrop of increasing CLI admissions over recent years. Patients with CLI received more endovascular interventions than surgical interventions over time. However, admissions for endovascular interventions were characterized by higher risk patient profiles and a higher risk of major amputations as compared with surgical interventions.

Hospital incidence, in-hospital mortality and medical costs of pneumococcal disease in Spain (2008–2017): a retrospective multicentre study

Objective The aim of this study was to analyze the characteristics of the patients attended with a pneumococcal disease in Spanish hospitals, to evaluate trends in hospital incidence and in-hospital mortality and to quantify patients’ use of resources and medical costs. Methods Medical admission records of patients admitted due to pneumococcal disease between 1 January 2008 and 31 December 2017 were obtained from a Spanish hospital discharge database. Records were identified with the International Statistical Classification of Diseases and Related Health Problems, 9th and 10th version codes corresponding to pneumococcal pneumonia, bacteraemia, pyogenic arthritis, endocarditis, meningitis, peritonitis and unspecified pneumococcal infections. Results Admissions of 168,074 patients were analyzed, with a mean age of 63.5 years (median = 72; interquartile range = 28). Pneumococcal pneumonia was responsible for 64.1% of all admissions, with a hospital incidence of 31.1 per 10,000 patients that decreased significantly over the study period (p = .002). Hospital incidence of meningitis also displayed a decreasing trend over the study period (p = .003), whereas incidence of bacteraemia and pyogenic arthritis increased significantly (p = .001; p = .004). Mean Charlson Comorbidity Index was 3.3 (standard deviation = 2.2). In-hospital mortality was 7.0% over the study period, being the highest in patients admitted with endocarditis (17.2%). Sepsis, acute renal failure, disorders of fluid electrolyte and acid-base balance, heart failure and acute respiratory failure were strongly associated with in-hospital mortality. Mean length of hospital stay was of 11.1 days (median = 22; interquartile range = 26) and there was a majority of urgent admissions (95.0%); the most extended stays were registered in patients with endocarditis, meningitis and pyogenic arthritis. The mean hospital admission cost was €5676, €104.2 million annually for all registered patients; 50.3% of all costs were associated with pneumonia, whereas the highest admission costs were registered in patients with endocarditis (€15,991) and meningitis (€11,934). Mean admission costs increased significantly over the study period for pneumonia and bacteraemia and decreased for endocarditis. Conclusions The incidence of pneumococcal pneumonia and meningitis decreased over the study period after the introduction of vaccination in Spain. The advanced age of patients and presence of chronic comorbid conditions that are associated to in-hospital mortality must be taken into account when improving care protocols and upcoming vaccination plans.

Trends and outcomes of mechanically ventilated cirrhotic patients in the United States from 2005-2014.

Cirrhotic patients in organ failure are frequently admitted to intensive care units (ICUs) to receive invasive mechanical ventilation (IMV). We evaluated the trends of hospitalizations, in-hospital mortality, hospital costs, and hospital length of stay (LOS) of IMV patients with cirrhosis. We analyzed the United States National Inpatient Sample from 2005-2014. We selected discharges of IMV adult (≥18 years) patients with cirrhosis using the International Classification of Diseases, 9th Edition, Clinical Modification codes. Trends were assessed using linear regression and joinpoint regression. Between 2005 and 2014, there were approximately 9,441,605 hospitalizations of IMV adult patients, of which 4.7% had cirrhosis. There was an increasing trend in the total number of IMV cirrhotic patient hospitalizations (annual percent change [APC] 7.0%, 95% confidence interval [CI] 6.4%; 7.6%, Ptrend < 0.001). The in-hospital case-fatality ratio declined between 2005-2011 (APC -2.9%, 95% CI, -3.4%; -2.4%, Ptrend < 0.001); however, it remained similar between 2011-2014 (Ptrend = 0.58). The total annual hospital costs of all IMV cirrhotic patients increased from approximately $1.2 billion USD in 2005 to $2.7 billion USD in 2014 (Ptrend < 0.001). The mean hospital costs per patient and mean LOS declined between 2005 and 2014 (Ptrend < 0.001 and Ptrend = 0.01 respectively). The total number of hospitalizations and total annual costs of IMV patients with cirrhosis have been increasing over time. However, past hesitancy around admitting cirrhotic patients to the ICU may need to be tempered by the improving mortality trends in this patient population.

Trends in morbidity and in-hospital mortality from cardiovascular diseases during COVID-19 pandemic

Trends in morbidity and in-hospital mortality from cardiovascular diseases during COVID-19 pandemic

Trends in head injury associated mortality in Malawi.

To address the problem of surgical workforce deficiencies in Malawi, we partnered with local institutions to establish a surgical residency-training and educational program for local surgeons in 2009. While this program has improved trauma-associated outcomes, it is unclear whether, without additional system improvements, the management of traumatic brain injury (TBI) has similarly advanced. This study sought to describe trends of TBI-associated in-hospital trauma mortality at a tertiary trauma center in sub-Saharan Africa. We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi, from 2012 through 2017. Modified Poisson regression modeling was used to compare the risk ratio of TBI associated in-hospital death each year compared to the year 2012, after adjusting for relevant covariates. 87,295 patients were recorded into the KCH Trauma Registry. 3,393 patients with TBI were identified, and most TBI patients were young males. In 2013 (RR 0.66, 95% CI 0.48, 0.92) and 2014 (RR 0.57, 95% CI 0.41, 0.79), the adjusted risk ratio of in-hospital death decreased compared to 2012 when adjusted for age, sex, initial AVPU score, transfer status, and multisystem trauma. However, the adjusted risk ratio of mortality in 2015 (0.73, 95% CI 0.53, 1.02) plateaued, with relatively minor improvements in 2016 (0.72, 95% CI 0.54, 0.97) and 2017 (0.71, 95% CI 0.53, 0.96). A decrease in TBI associated mortality was associated with the establishment of a residency and educational training program for general surgery. This program increased available surgeons, improved critical care and trauma training, and integrated some neurosurgical training. However, improvements in outcomes plateaued in the last few years of the study, despite these enhancements to surgical care. The general surgery workforce must be supplemented with improved neurosurgical services and neurocritical care to decrease TBI-related mortality.

268. Clinical Characteristics and Mortality Associated with Culture Positivity in Adult Inpatients with Sepsis: A 15-Year Cohort Study of 48,706 Patients at a Tertiary Medical Center in Taiwan

BackgroundCulture-negative (CN) sepsis occurs in 30~60% of sepsis patients. Understanding CN sepsis is crucial for treatment optimization. We used an electronic medical records (EMR)-based surveillance proposed by Rhee et al. to identify patients with sepsis meeting Sepsis-3. We aimed to describe the trend of sepsis and mortality, and to study the characteristics and mortality associated with culture positivity.MethodsThis cohort study included adult (>=18 years) inpatients with first-time sepsis who were admitted to our hospital during 2003–2017 (Figure 1). Sepsis was identified using clinical indicators of presumed infection and concurrent acute organ dysfunction. Culture-positive (CP) sepsis were those whose blood grew non-commensal organisms for > = 1 blood draw and those whose blood grew commensal organisms for > = 2 blood draws. Mortality were ascertained by the National Cause of Death Database. Multivariable Cox proportional hazard model was used to evaluate the effect of culture positivity on all-cause mortality.Figure 1. Selection Process of the Study Population (N = 48,706). ResultsOf 48,706 adult inpatients with first-time sepsis, 41,304 (84.8%) were CN. The sepsis rate increased from 4.6% to 8.7%, while in-hospital mortality significantly decreased from 30.2% to 14.5% (Figure 2). Patients with CN sepsis tended to be younger, male, less diabetes, liver cirrhosis but more cardiovascular disease, and received systemic antibiotic within 14 days prior (Table 1). Serum biochemical profiles of procalcitonin, hs-CRP, and lactate were significantly lower in CN sepsis. Mechanical ventilation and respiratory site of infection were more likely to be presented in CN sepsis. Overall, the mortality (in-hospital, 7-day, 30-day, 1-year) was lower in CN sepsis. After adjusting for confounders, culture positivity was significantly associated with 7-day mortality (aHR 1.21; 95% CI 1.08, 1.37) (Table 2).Figure 2. The Trend of Sepsis Rate (A) and In-hospital Mortality (B) of Adult Inpatients with Sepsis, 2003–2017 at CMUH. Table 1. Baseline Demographic and Clinical Characteristics of the Adult Inpatients with Sepsis, 2003–2017 at the CMUH (N = 48,706). Table 2. Hazard Ratio (95% Confidence Interval) for Mortality Associated with Culture-Positive Sepsis. ConclusionSepsis rate increased while the mortality decreased, indicating the improvement of sepsis management in the past 15 years. The clinical characteristics of CN and CP sepsis were comparable, except for the lower inflammatory markers found in CN sepsis. Patients with CP sepsis had 21% higher risk of 7-day mortality. Next, we will link with National Health Insurance Database to examine admission history and antibiotic use in other institutions.Disclosures All Authors: No reported disclosures

Trends, Outcomes, and Predictive Score For Emergency Coronary Artery Bypass Graft Surgery After Elective Percutaneous Coronary Intervention (from a Nationwide Dataset)

The temporal trends and preprocedural predictors of emergency coronary artery bypass graft surgery (ECABG) after elective percutaneous coronary intervention (PCI) in the contemporary era are largely unknown. From January 2003 to December 2014 elective hospitalizations with PCI as the primary procedure were extracted from the Nationwide Inpatient Sample. ECABG was identified as CABG within 24 hours of elective PCI. Temporal trends of elective PCI, ECABG, comorbidities, and in-hospital mortality were analyzed. Logistic regression model was used to identify preprocedural independent predictors of ECABG and post-PCI ECABG risk score was developed using the regression coefficients from the logistic regression model in the development cohort. The score was then validated in the validation cohort. Of 1,605,641 elective PCI procedures included in the final analysis, 5,561 (0.3%) patients underwent ECABG. The incidence of ECABG, co-morbidities and overall in-hospital mortality increased over the study period, whereas the in-hospital mortality after ECABG remained unchanged. An increasing trend of elective PCI performed at facilities without on-site CABG was noted, with a higher unadjusted in-hospital mortality in this cohort. ECABG risk score, performed well with a significantly higher risk of ECABG in those patients with a score in the highest tertile compared with those with lower ECABG score (0.6% vs 0.3%, p = 0.0005). In conclusion, an increasing trend of adverse outcomes after elective PCI is observed. We describe an easy-to-use predictive score using preprocedural variables that may allow the operator to triage the patient to an appropriate setting in an effort to improve outcomes.

Recent Trends in Admission Diagnosis and Related Mortality in the Medically Critically Ill.

With decades of declining ICU mortality, we hypothesized that the outcomes and distribution of diseases cared for in the ICU have changed and we aimed to further characterize them. A retrospective cohort analysis of 287,154 nonsurgical-critically ill adults, from 237 U.S. ICUs, using the manually abstracted Cerner APACHE Outcomes database from 2008 to 2016 was performed. Surgical patients, rare admission diagnoses (<100 occurrences), and low volume hospitals (<100 total admissions) were excluded. Diagnoses were distributed into mutually exclusive organ system/disease-based categories based on admission diagnosis. Multi-level mixed-effects negative binomial regression was used to assess temporal trends in admission, in-hospital mortality, and length of stay (LOS). The number of ICU admissions remained unchanged (IRR 0.99, 0.98-1.003) while certain organ system/disease groups increased (toxicology [25%], hematologic/oncologic [55%] while others decreased (gastrointestinal [31%], pulmonary [24%]). Overall risk-adjusted in-hospital mortality was unchanged (IRR 0.98, 0.96-1.0004). Risk-adjusted ICU LOS (Estimate -0.06 days/year, -0.07 to -0.04) decreased. Risk-adjusted mortality varied significantly by disease. Risk-adjusted ICU mortality rate did not change over the study period, but there was evidence of shifting disease burden across the critical care population. Our data provides useful information regarding future ICU personnel and resource needs.

In-Hospital acute ischemic stroke following ST-elevation myocardial infarction.

BackgroundIn-hospital ischemic stroke following acute ST-elevation myocardial infarction (STEMI) has not been evaluated on a national scale in the United States.MethodsWe used 2003 to 2014 Nationwide Inpatient Sample data to identify adults with a principal diagnosis of STEMI. Patients were divided into two groups defined by presence or absence of ischemic stroke. Clinical characteristics and in-hospital outcomes were studied using relevant statistics. Multiple linear and logistic regression models identified factors associated with ischemic stroke, national trend of in-hospital stroke incidence and in-hospital mortality.ResultsOf 1,842,529 STEMI patients hospitalized from 2003 to 2014, 22,268 (1.2%) developed acute in-hospital ischemic stroke. Those with acute strokes were older (age ≥ 65 years: 70% vs 46%), more likely female (51% vs 33%), and had higher rates of atrial fibrillation (28.9% vs 12.2%) and heart failure (40.5% vs 21.1%). Age and gender adjusted incidence of in-hospital ischemic stroke following STEMI remained stable; 1.4% in 2003 and 1.5% in 2014 (P trend = 0.50). However, age and gender adjusted in-hospital mortality declined in STEMI patients with and without in-hospital ischemic stroke [AOR 0.97 (0.95–0.99) P trend = 0.03, and AOR 0.98 (0.98–0.99) P trend < 0.001, respectively]. Patients with ischemic strokes had higher in-hospital mortality (25.7% Vs 7.2%, p < 0.001), [AOR 2.11, 95% CI (1.92–2.32)].ConclusionIn the United States, the incidence of acute in-hospital stroke remained stable from 2003 to 2014 following STEMI with significant decrease of in-hospital mortality trends. Despite slight improvement in mortality trends, in-hospital mortality rates remained elevated calling for interventions to optimize health care delivery.

Trends in Hospitalization Rates, Major Causes of Hospitalization, and In-Hospital Mortality in Rheumatoid Arthritis in the United States From 2000 to 2014.

ObjectiveTo evaluate national trends in hospitalizations and in‐hospital mortality in rheumatoid arthritis (RA).MethodsNational Inpatient Sample from 2000‐2014 and United States Census data were used to study temporal trends in adult RA hospitalizations, reasons for hospitalizations, and in‐hospital mortality.ResultsThe data represented 183 983 hospitalizations with a primary diagnosis of RA. The annual rates of hospitalization for the primary diagnosis of RA decreased from 76.54 admissions per 1 million in 2000 to 29.96 per 1 million in 2014 (P trend < 0.0001). The hospital mortality rate declined from 0.70% to 0.41% (P trend < 0.0001) in this group. With a primary or nonprimary diagnosis of RA, the mortality rate ranged between 1.95 and 2.87 (P trend 0.08). For a nonprimary diagnosis of RA, we noted that the proportion of hospitalizations with a diagnosis of myocardial infarction (6.4% in 2000 to 4.6% in 2014; P < 0.001) significantly decreased, but the absolute number of hospitalizations significantly increased. In contrast, the proportion and the absolute number of hospitalizations with any diagnosis of sepsis, congestive heart failure, lung disease, and urinary tract infection increased significantly. We also noted a significant increase in the actual rate and proportions for hospitalizations for hip and knee arthroplasty. Among in‐hospital deaths when RA was a nonprimary diagnosis, the most common primary diagnosis was pneumonia (12.5 %) in 2000, whereas sepsis accounted for the most deaths in 2014 (31.4%).ConclusionWe observed that hospitalization rates and in‐hospital mortality rates in patients with RA have changed significantly over the past 15 years.

Abstract 16190: Trends in Admissions and Outcomes in Patients With Chronic Limb-threatening Ischemia-a National Inpatient Sample Analysis

Introduction: Chronic limb threatening ischemia (CLTI) morbidity and mortality rates have historically been higher, however recent trends have not been reported. In patients admitted with CLTI, we aimed to examine trends in in-hospital mortality, major amputations, length of stay, and cost of admissions overall, and stratified by type of revascularization procedures. Hypothesis: We hypothesized there would be an increase in CLTI-related admissions, with outcomes only marginally improving. Methods: Using 2011-2017 National Inpatient Sample data, we identified CLTI-related admissions based on ICD-9 and 10-CM codes. We stratified outcomes based on endovascular or open surgical interventions. We also performed multivariable regression analyses based on age, sex, race, hospital size, type and location. Results: We identified 2,643,087 CLI-related admissions between 2011 and 2017. CLI admissions increased from 0.9% to 1.4% P trend &lt;0.0001 as well as overall PAD admissions (4.5% to 8.9%, P trend &lt;0.0001). In-hospital mortality for the entire CLTI cohort decreased from 3.3% to 2.7%, P trend &lt;0.0001 and major amputations decreased from 10.9% to 7%, P trend &lt;0.0001. A decline was also noted for length of stay from 5.7 (3.1-10.1) to 5.4 (3.0-9.2) (P trend &lt;0.0001), whereas admission costs increased from 11,791 (6,676 - 21,712) to 12,597 (7,248 - 22,748) (P trend &lt;0.0001). The volume of endovascular interventions increased (P&lt;0.0001) against a decline in surgical interventions (P&lt;0.0001). Black race, female sex and age ≥60 years were associated with higher in-hospital mortality. Conclusions: A relatively small decrease in absolute numbers for mortality and major amputations were observed against a backdrop of increasing CLTI admission volumes over recent years. As patients with CLTI receive more endovascular interventions than surgical interventions over time, mortality rates and length of stay have generally improved.

Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States.

To determine trends in real-world utilization and in-hospital adverse events from Watchman implantation since its approval by the Food and Drug Administration in 2015. The risk of embolic stroke caused by atrial fibrillation is reduced by oral anticoagulants, but not all patients can tolerate long-term anticoagulation. Left atrial appendage occlusion with the Watchman device has emerged as an alternative therapy. This was a retrospective cohort study utilizing data from National Inpatient Sample for calendar years 2015-2017. The outcomes assessed in this study were associated complications, in-hospital mortality, and resource utilization trends after Watchman implantation. Trends analysis were performed using analysis of variance. Multivariable adjusted logistic regression analysis was performed to determine predictors of mortality. A total of 17 700 patients underwent Watchman implantation during the study period. There was a significantly increased trend in the number of Watchman procedures performed over the study years (from 1195 in 2015 to 11 165 devices in 2017, p < .01). A significant decline in the rate of complications (from 26.4% in 2015% to 7.9% in 2017, p < .01) and inpatient mortality (from 1.3% in 2015% to 0.1% in 2017, p < .01) were noted. Predictors of in-hospital mortality included a higher CHA2 DS2 -VASc score (odds ratio [OR]: 2.61 per 1-point increase, 95% confidence interval [CI]: 1.91-3.57), chronic blood loss anemia (OR:3.63, 95% CI: 1.37-9.61) and coagulopathy (OR: 4.90, 95% CI: 2.32-10.35). In contemporary United States clinical practice, Watchman utilization has increased significantly since approval in 2015, while complications and in-patient mortality have declined.

In-hospital mortality trends among patients with idiopathic pulmonary fibrosis in the United States between 2013-2017: a comparison of academic and non-academic programs

BackgroundIdiopathic pulmonary fibrosis (IPF) is a devastating condition characterized by progressive lung function decline and early mortality. While early accurate diagnosis is essential for IPF treatment, data evaluating the impact of hospital academic status on IPF-related mortality remains limited. Here we examined in-hospital mortality trends for patients with IPF from 2013 to 2017. We hypothesized that in-hospital IPF mortality would be influenced by hospital academic setting.MethodsHospitalization data was extracted from the National Inpatient Sample (NIS) for subjects with an international classification of disease code for IPF. In-hospital mortality stratified by hospital setting (academic versus non-academic) was the primary outcome of interest, with secondary analyses performed for subgroups with and without respiratory failure and requiring mechanical ventilation. Predictors of mortality were then assessed.ResultsAmong 93,680 patients with IPF requiring hospitalization, 58,450 (62.4%) were admitted to academic institutions. In-hospital mortality decreased significantly in those admitted to an academic hospital (p < 0.001) but remained unchanged in patients admitted to a non-academic hospital. A plateau in-hospital mortality was observed among all hospitalized patients (p = 0.12), with a significant decrease observed for patients with admitted respiratory failure (p < 0.001) and those placed on mechanic ventilation (p < 0.001).ConclusionIn-hospital mortality decreased significantly for patients with IPF admitted to an academic hospital, suggesting that management strategies may differ by hospital setting. Mortality among those with respiratory failure and those requiring mechanical ventilation has dropped significantly. Our findings may underscore the importance of promoting early referral to an academic institution and adherence to international treatment guidelines.