Urban Nonteaching Hospitals Research Articles

Demographic-based disparities in outcomes for adults with central line-associated bloodstream infections in the United States: a National Inpatient Sample database study (2016-2020).

Central line-associated bloodstream infections (CLABSI) are prevalent and preventable hospital-acquired infections associated with high morbidity and costs. Disparities based on race, ethnicity, and hospital factors remain underexplored. This study compares cost, length of stay, and mortality for adults with CLABSI by race-ethnicity, hospital location-teaching status, and geographic region in the United States using data from the National Inpatient Sample (NIS) database from 2016 to 2020. The hospitalization cohort included adults diagnosed with CLABSI, excluding those with primary CLABSI diagnoses, cancer, immunosuppressed states, or neonatal conditions. Primary outcomes were in-hospital mortality, length of stay, and hospital costs, adjusted to mid-year 2020 US dollars. Independent variables included race-ethnicity, hospital location-teaching status, and geographic region. All analyses accounted for NIS sampling design. From 2016 to 2020, there were approximately 19,835 CLABSI hospitalizations. The overall in-hospital mortality rate was 9.1%, with a median hospital stay of 16.9 days and median cost of $44,810. Hispanic patients experienced significantly higher mortality, longer length of stay, and higher costs compared to non-Hispanic Black and White patients. Urban teaching hospitals had longer stays and higher costs than rural and urban non-teaching hospitals. Regionally, the Northeast and West had higher costs and longer stays than the Midwest and South, but mortality rates did not differ significantly. This study highlights significant disparities in CLABSI outcomes based on demographic factors. Addressing these disparities is crucial for improving CLABSI management and healthcare equity. Further research should explore the underlying causes of these differences to inform targeted interventions.

Comparative Outcomes of Peritoneal Dialysis across Different Hospital Settings: An Analysis of Urban Teaching, Urban Nonteaching, and Rural Hospitals

Comparative Outcomes of Peritoneal Dialysis across Different Hospital Settings: An Analysis of Urban Teaching, Urban Nonteaching, and Rural Hospitals

Prevalence and Factors Associated With Palliative Care Utilization Among Hospitalized Patients With Gallbladder Cancer- A National Inpatient Sample Analysis.

Various factors have been associated with palliative utilization in different cancers. However, literature is still lacking on the prevalence and factors associated with palliative care use in gallbladder cancer (GBC). This study aims to determine the prevalence of palliative care utilization and examine the factors associated with palliative care utilization among patients with GBC. We conducted a retrospective analysis using the National Inpatient Sample between 2016 and 2018. Descriptive statistics were used to characterize the study population. We explored factors associated with palliative care utilization among hospitalized GBC patients using logistic regression. Of the 20280 GBC hospitalizations, 18.0 % utilized palliative care. Multivariable analysis revealed that treatment at urban teaching hospitals, or treatment at urban nonteaching hospitals, Medicare insurance, other insurance coverage, transfer to a facility/discharge with home health, and death during hospital stay were associated with higher utilization of palliative care. In contrast, non-elective admissions were associated with decreased odds of palliative care utilization. Palliative care use among GBC patients is still low at 18.0%. Palliative care use was associated with insurance disparities, discharge disposition, hospital location, and type of admission. Therefore, concerted efforts to address these disparities in palliative care utilization are needed to improve the quality of care for this population.

Outcomes of Upper Gastrointestinal Bleeding at United States Teaching and Non-teaching Hospitals: A National Inpatient Sample Analysis.

Studies have varied results regarding the impact of the teaching and non-teaching status of hospitals on the outcomes for hospitalized patients with upper gastrointestinal bleeding (UGIB). To evaluate these outcomes, we conducted a retrospective cohort study using the 2014 National Inpatient Sample (NIS) database. We included all adult patients who were admitted with the principal diagnosis of UGIB. Patients admitted to rural and urban non-teaching hospitals were classified as non-teaching, whereas those admitted to urban teaching hospitals were classified as teaching. The main outcomes of interest were in-hospital mortality, percentage of patients requiring inpatient endoscopy, and endoscopic therapy, packed red blood cell (PRBC) transfusion, length of stay (LOS), and total hospitalization charges. The study included 132,085 (97%) with nonvariceal UGIB (NVUGIB) and 4,200 (3%) with variceal UGIB (VUGIB). Of them, 62% were managed at teaching hospitals. Compared with admitted patients at non-teaching hospitals, patients with nonvariceal UGIB admitted at teaching hospitals had similar adjusted in-hospital mortality rates (adjusted odds ratio (OR): 0.97, 95% confidence interval (CI): 0.79-1.19), inpatient endoscopy rates (OR: 0.98, 95% CI: 0.91-1.1), and early endoscopy rates (within 24 hours) (OR: 0.98, 95% CI: 0.91-1.1) and lower PRBC transfusionrates (OR: 0.87, 95% CI: 0.79-0.97) but higher endoscopic therapyrates (OR: 1.3, 95% CI: 1.2-1.4), length of stay (mean increase of 0.43 days) (P<0.01), and total hospital charges (mean increase of $4,369) (P<0.01). Patients with variceal UGIBhad similar adjusted in-hospital mortality rates (OR: 1.2, 95% CI: 0.61-2.3), inpatientendoscopy rates (OR: 0.97, 95% CI: 0.67-1.4), early endoscopy rates (within 24 hours) (OR: 0.97, 95% CI: 0.67-1.4), endoscopic therapy rates (OR: 2.5, 95% CI: 0.54- 11.2), and total hospital charges (P=0.45), and lower PRBC transfusionrates (OR: 0.63, 95% CI: 0.45-0.88) but higher length of stay (mean increase of 0.69 days) (P=0.02). Patients with nonvariceal UGIB treated at US teaching hospitals and non-teaching hospitals have similar mortality, rates of in-hospital endoscopy, and early endoscopy, but teaching hospitals have higher rates of in-hospital therapeutic endoscopy, length of stay, and total hospital charges. There was no difference in any of the outcomes for varicealgastrointestinal (GI) bleeding treated at teaching hospitals compared with those treated at non-teaching hospitals, except for length of stay, which was higher among patients admitted to teaching hospitals compared to those admitted tonon-teaching hospitals.

Trends and Distribution of IPAAs in the United States: Becoming Harder to Find in Colon and Rectal Surgery Residency Training?

There has been concern among colon and rectal surgery residency programs in the United States that IPAA procedures have been decreasing, but evidence is limited. The study aimed to evaluate the number of IPAAs performed by colon and rectal surgery residents in the United States and analyze the distribution of these cases on a national level. Retrospective. The Accreditation Council for Graduate Medical Education Case Log National Data Reports were used to evaluate the number of IPAAs performed by residents from 2005 to 2021. The Nationwide Inpatient Sample database was used to identify all patients undergoing these procedures from 2005 to 2019. All IPAA procedures regardless of indication. The primary outcome was the number of IPAAs performed by residents yearly. The secondary outcome was the national distribution of these procedures. Among colon and rectal surgery residents, case log data revealed an increase in mean and total number of IPAAs from 2005 to 2013, followed by a decline in both metrics after 2013. Despite the decrease, the mean number of cases per resident remained fewer than 6 between 2011 and 2021. A weighted national estimate of 48,532 IPAA patients were identified in the Nationwide Inpatient Sample database. A significant decrease was noted in the number of IPAAs after 2015 that persisted through 2019. There was a significant decrease in rural and urban nonteaching hospitals (from 2.1% to 1.6% and 25.6% to 4.3%, respectively; p < 0.001) and an increase in urbanteaching hospitals (from 72.4% to 94.1%; p < 0.001). Nonrandomized retrospective study design. Despite the recent increase in the percentage of IPAAs performed at urban academic centers, there has been a decrease in cases performed by colon and rectal surgery residents. This can have significant implications for residents who graduate without adequate experience in performing this complex procedure independently, as well as training programs that may face challenges with maintaining accreditation. See Video Abstract. ANTECEDENTES:Ha habido preocupación entre los programas de capacitación de residencia en cirugía de colon y recto en los Estados Unidos porque los procedimientos de anastomosis anal con bolsa ileal han estado disminuyendo; sin embargo, la evidencia es limitada.OBJETIVO:Evaluar el número de anastomosis anales con bolsa ileal realizadas por residentes de cirugía de colon y recto en los Estados Unidos y examinar la distribución de estos casos a nivel nacional.DISEÑO:Retrospectivo.AJUSTES:Se utilizaron los informes de datos nacionales del registro de casos de educación médica de posgrado del Consejo de Acreditación para examinar el número de anastomosis anales con bolsa ileal realizadas por residentes de 2005 a 2021. Se utilizó la base de datos de muestra nacional de pacientes hospitalizados para identificar a todos los pacientes sometidos a estos procedimientos de 2005 a 2019.PACIENTES:Todos los procedimientos de anastomosis anal con bolsa ileal independientemente de la indicación.MEDIDA DE RESULTADO PRINCIPAL:El resultado primario es el número de anastomosis anales con bolsa ileal realizadas por los residentes anualmente. El resultado secundario es la distribución nacional de estos procedimientos.RESULTADOS:Entre los residentes de cirugía de colon y recto, los datos de los registros de casos revelaron un aumento en el número medio y total de anastomosis anal con bolsa ileal de 2005 a 2013, seguido de una disminución en ambas métricas después de 2013. A pesar de la disminución, el número medio de casos por El residente permaneció >6 entre 2011 y 2021. Se identificó una estimación nacional ponderada de 48 532 pacientes con anastomosis anal con bolsa ileal en la base de datos de la Muestra Nacional de Pacientes Hospitalizados. Se observó una disminución significativa en el número de anastomosis anales con bolsa ileal después de 2015 que persistió hasta 2019. Hubo una disminución significativa en los hospitales no docentes rurales y urbanos (del 2,1% al 1,6% y del 25,6% al 4,3% respectivamente, p < 0,001) y un aumento en los hospitales universitarios urbanos (del 72,4% al 94,1%, p < 0,001).LIMITACIONES:Estudio retrospectivo no aleatorizado.CONCLUSIÓN:A pesar del reciente aumento en el porcentaje de anastomosis anal con bolsa ileal realizadas en centros académicos urbanos, ha habido una disminución en los casos realizados por residentes de cirugía de colon y recto. Esto puede tener implicaciones significativas para los residentes que se gradúan sin la experiencia adecuada en la realización de este complejo procedimiento de forma independiente, así como para los programas de capacitación que pueden enfrentar desafíos para mantener la acreditación. (Traduccion-AI-generated).

Temporal and institutional trends in robotic surgery.

Robotic surgery has become increasingly prevalent in general surgery practice. While previous studies have shown the safety and efficacy of robotic assistance in laparoscopic general surgery procedures, few studies have evaluated the temporal and regional trends in implementation. In our retrospective population-based study, we aim to evaluate the national trends in robotic surgery. National Inpatient Database (NIS 2009-2014) was used to identify adults who underwent robotic assisted surgery (ICD 9 codes 17.41 to 17.49). Robotic procedures related to seven abdominal organ systems were compared against the trends of Urology, Gynaecologic, and Orthopedic robotic procedures. Discharge weights were applied to calculate National temporal trends separated by hospital size, teaching status and US geographic region. 894,163 patients received a robotic assisted procedure between 2009 and 2014 with 64% increase in utilization. The largest percent change was witnessed in biliary robotic procedures with 2984% change in utilization, followed by hernia (1376%). Lowest percent change was witnessed in esophageal procedures with 114% increase. Medium sized hospitals had the largest change in robotic utilization (41%), with large institutions seeing 18% decrease. Gastric procedures were the most common robotic procedure performed at small institutions (7917 total cases; 316%). Large institutions saw an overall decrease in gastric (-47%), esophageal (-17%), small and large intestinal (-16%), and hepatic (-7%) robotic procedures. Rural non-teaching hospitals saw the largest increase in robotic surgery (274%). Urban non-teaching hospitals saw a decrease of 29%. While urban teaching institutions saw a 20% and 6% increase in gynecological and urological procedures, an overall decrease was seen in esophageal (-10%), gastric (-12%), intestinal (-11%), hepatic (-17%), biliary (-10%), pancreatic (-11%) and hernia procedures (-14%). Biliary procedures saw the largest increase in rural institutions (740 cases; 392%), followed by hernia (144% increase). South region of the nation had the largest increase in robotic procedures (23%). No change was seen in the use of robotic surgery in the northeast region with the midwest and west seeing an overall decrease (-4% and -22%, respectively). Our study highlights the increase in use of robotics for both general and specialty surgery, with an increase in utilization over time. Increased incidence of robotic surgery in smaller, rural institutions with overall decrease in larger, urban teaching hospitals suggests increasing comfort in robotic surgery in the community setting. Further studies are necessary to evaluate the factors associated with increased utilization in smaller institutions.

Relationship between patient safety indicator events and hospital location for inpatient hysterectomy.

Previous studies suggest surgical quality outcomes are similar between rural and urban hospitals, but data about gynecology in rural hospitals is sparse. This was a retrospective cohort study utilizing the National Inpatient Sample database from the Agency of Healthcare Research and Quality. Patients who underwent benign hysterectomy for non-prolapse indications between 2012-2016 were identified using ICD-9 and 10 codes. Patients were stratified into rural or urban non-teaching groups; urban teaching hospitals were the referent group. The primary outcome was the rate of patient safety indicator (PSI) events. PSI events were identified using ICD-9 and 10 codes. Statistical analysis was performed using analysis of variance and uni- and multivariate Poisson regressions. 154,810 patients met all inclusion criteria. The cumulative rate of PSI events was 11.9% at rural hospitals, 13.9% at urban non-teaching hospitals and 16.9% at urban teaching hospitals, P<0.001. The most common PSI events were postoperative metabolic derangement, hemorrhage, and accidental puncture. The rate of transfusion was highest in urban teaching hospitals (6.7%) and similar for rural (5.1%) and urban non-teaching hospitals (5.5%), P<0.001. The rate of genitourinary tract injury was between 1.4-1.6%, and similar across sites, P=0.89. After adjusting for confounders, the risk of PSI events was similar across locations. The risk of transfusion was lower at rural hospitals (aRR=0.84, 95% CI: 0.74-0.94). Hysterectomy performed at rural hospitals, typically thought of as having low surgical volume compared to urban hospitals, is associated with similar risk of PSI events and lower risk of transfusion.

(361) National Trends of Male Urethroplasty Procedures: 2016-2019

Abstract Introduction Urethroplasty remains a valuable surgical option in the management of urethral stricture disease. However, current understanding of the patient- and hospital-level factors associated with inpatient versus (vs.) outpatient male urethroplasty is limited on a national scale. Objective We therefore sought to evaluate contemporary national trends of urethroplasty procedures among men. Methods We performed a retrospective review from 2016 to 2019 of urethroplasty procedures in men utilizing both the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample – the largest publicly available all-payer inpatient and ambulatory databases in the United States. Non-endoscopic urethroplasty procedures were identified by Current Procedural Terminology and International Classification of Diseases (10th Revision) Procedure Coding System codes. Utilizing both inpatient and outpatient encounters, we performed stratified cluster sampling to create weighted national estimates. The primary outcome was the rate of urethroplasty performed in inpatient and outpatient encounters over time. Multivariable logistic regression was used to evaluate patient- and hospital-level factors associated with inpatient urethroplasty. Results From 2016 to 2019, there were 28,532 weighted urethroplasty procedures analyzed (37% inpatient vs. 63% outpatient). Over the study period, there was a 27% increase in the total number of annual procedures (n=6270 to n=7980), and the proportion performed outpatient increased from 60% to 68% [Figure]. Mean total charge for inpatient urethroplasty encounters was $84,267 vs. $30,997 outpatient (p&amp;lt;0.0001). Predictors of inpatient urethroplasty included greater Elixhauser Comorbidity Index, use of buccal mucosal graft, non-private insurance status, and Western hospital region (vs. Northeast) (p&amp;lt;0.05) [Table]. Outpatient urethroplasty was associated with higher median income by Zip Code (vs. lowest quartile of median income), Southern hospital region (vs. Northeast), rural or urban non-teaching hospital (vs. urban teaching hospital), and higher urethroplasty case volume hospitals (vs. lowest case volume hospitals) (p&amp;lt;0.05). Conclusions An increasing proportion of urethroplasty procedures nationwide appears to be performed on an outpatient basis. Outpatient procedures have lower hospital charges than inpatient encounters – and are associated with higher volume hospitals, not using buccal mucosal graft, private insurance, and less comorbid patients who reside in areas of higher median income. Further investigation is warranted to assess how these factors may affect surgical outcomes. Disclosure No.

SOCIOECONOMIC DISPARITIES IN HOSPITALIZATION AND OUTCOMES OF EOSINOPHILIC COLITIS: A FIVE-YEAR NATIONAL ANALYSIS

Abstract BACKGROUND Eosinophilic colitis (EoC) is a rare gastrointestinal inflammation of the colon due to an altered hypersensitivity reaction characterized by eosinophilic infiltration into the colonic wall. Patients usually present with abdominal pain, diarrhea, and weight loss. METHODS We used the National Inpatient Sample (NIS) database to conduct a retrospective study of hospitalized adult patients with eosinophilic colitis using the validated ICD-10 diagnosis codes between January 1, 2016, and December 31, 2020. RESULTS We identified 4353 cases of eosinophilic colitis using the NIS database. There were 748, 776, 889, 934, and 1,006 eosinophilic colitis cases diagnosed in 2016, 2017, 2018, 2019, and 2020 respectively. Males were more likely to be hospitalized due to eosinophilic colitis than females (51.8% vs. 48.2%). Moreover, there was a significantly higher prevalence of eosinophilic colitis among the white population, with 81.7% in Whites, 8.1% in Blacks, 6.3% in Hispanics, and 1.3% in Asians. 26.5% of those patients had Medicare, 15.7% had Medicaid, and 50.6% had private/HMO insurance. About 20.7% of patients had a median household income of $45,999 or less, 23.6% had $46,000-58,999, and 55.6% had $59,000 or more. Based on hospital location, 30.3% of the cases were in the South, 27.5% in the Midwest, 23.4% in the West, and 18.8% in the Northeast. The majority of patients admitted for eosinophilic colitis were recorded in urban teaching hospitals (77.8%) compared to 17.6% in urban nonteaching hospitals and 4.6% in rural areas. Only 16.5% of the patients with eosinophilic colitis had a Charlson Comorbidity Index of 3 or higher. CONCLUSION Based on the national inpatient sample over 5 years, males and whites are more likely to be hospitalized with eosinophilic. The report suggests that eosinophilic colitis is common among patients with high median household income and has a better prognosis.

The Determinants of Inpatient Palliative Care Use in Patients With Pancreatic Cancer.

Symptom burden management is a major goal of pancreatic cancer care given that most patients are diagnosed late. Early palliative care is recommended in addition to concurrent active treatment; however, disparities exist. We sought to determine the factors associated with inpatient palliative treatment among pancreatic cancer patients and compare treatment outcomes in terms of mortality, discharge disposition and resource utilization. We conducted a retrospective study of 22,053 pancreatic cancers using the National Inpatient Sample (NIS) database (January - December 2020). Patient and hospital characteristics, mortality, discharge disposition, length of stay (LOS), hospital costs and charges were compared between pancreatic cancer patients based on palliative treatment. Multivariate regression was used to evaluate patient and hospital characteristics and outcomes associated with palliative treatment. A total number of 3839 (17.4%) patients received palliative care. Patients who received palliative care were more likely to be older, Medicaid insured, and nonobese. Patients were less likely to receive palliative care if they are males, Medicare insured, had a lower Charlson comorbidity score, or treated in Urban nonteaching hospitals. Patients who received palliative care displayed higher odds of in-hospital mortality and prolonged LOS. The adjusted additional mean hospital cost and charges in patients who received palliative care were lower by $1459, and $4222 respectively. Inpatient palliative treatment in pancreatic cancer patients is associated with an older age, a higher comorbidity burden, non-obesity, insurance status and urban teaching hospitals. Our study suggests that inpatient palliative treatment decreased hospital resource utilization without prolonging survival.

The association between obesity and mortality in otherwise metabolically healthy COVID-19 patients with cardiac arrest: insights from a National Inpatient Sample in the US, 2020

Abstract Background Existing studies suggest poor outcomes among SARS-CoV-2 patients who had underlying obesity and metabolic syndrome (MBS). Therefore, we planned to do this study as no study so far has assessed the association of obesity with outcomes in individuals with SARS-CoV-2 infection who are metabolically healthy. Methods We queried the National Inpatient Sample (2019) using the ICD-10 codes for COVID-19 patients who had a cardiac arrest and were metabolically healthy (without Hypertension, Hyperlipidemia and Diabetes). Baseline characteristics, comorbidities, healthcare resource utilization statistics, and all-cause mortality were compared between obese and non-obese cohorts. Multivariable regression analyses were performed adjusting for demographics, hospital-level characteristics, and relevant comorbidities. Results After cleaning the data for missing data total COVID-19 with cardiac arrest-related hospitalizations were 5885 (obese 1410 vs non-obese 4475). Propensity score matching, 1:1 ratio, for age, sex and race led to a final population of 2140 (obese 1070 vs non-obese 1070). In propensity-matched samples, COVID-19 with cardiac arrest with obesity were mainly black (42.1% vs 37.9%; p=0.03), private payer (43.1% vs 24.5%; p&amp;lt;0.001), visiting the urban non-teaching hospital (26.2% vs 16.8%; p&amp;lt;0.001) compared to non-obese. Besides, COVID-19 patients with cardiac arrest were smokers (15.4% vs 13.6%), high burden of peripheral vascular disease, and had prior coronary artery bypass grafts. Before matching, 1510 obese patients with COVID-19 with cardiac arrest, 1300 (86.10%) died vs 4105 (81.7%) of 5025 non-obese with cardiac arrest; p&amp;lt;0.05. Besides, obese patients had significantly high all-cause mortality (83.6% vs 78.0%; p=0.001), transfer to short-term hospital (17.1% vs 11.4%; p=0.001), and high hospital cost (median $434336 vs $338450; p=0.001) compared to non-obese patients in propensity match cohort [Table 1]. Furthermore, in the subgroup analysis, high mortality in obese patients was noted in young Age 18-44 years, 45-64 years, in females, White, black, low household income,0-25, (88.9% vs 77.9%;p&amp;lt;0.001) compared to non-obese patients. However, after adjustment for covariates, the odd for all-cause mortality in patients with obesity was high (OR 1.67; CI 95%, 0.99-2.82), but failed to attain significance [Table 2]. Conclusion The burden of obesity in otherwise metabolically healthy COVID-19 patients admitted with cardiac arrest remained very high (nearly 1 in every 4 patients). COVID-19 patients with cardiac arrest had higher mortality in obese patients, especially those of young age, female and low-income patients. However, when adjusted for covariates the multivariate analysis failed to reach a statistical significance which warrant further large-scale studies to understand the independent association of higher BMI or obesity on survival in this high-risk patient population.

Abstract 17997: Contemporary Trends in Coronary Artery Anomalies

Introduction: Coronary artery anomalies (CAA) are a group of congenital conditions whose prognostic significance is still widely debated. In part, this is due to the limited data on CAA, given its general incidental nature. Data on age, gender, and ethnic disparities is even more scarce. Hypothesis: There is an increase in prevalence of CAA over time with unchanged difference in mortality. Methods: The National Inpatient Sample (NIS) database was queried between 2016-2019 to identify hospitalizations with CAA. The primary outcome was in-hospital mortality. Secondary outcomes included type of hospital, region, age, and complications. Linear regression and Chi-squared were used for analysis. Results: Our study identified 7,821 patients diagnosed with CAA. There was a significant increase in the prevalence of CAA from 1,961 in 2016 to 2,127 in 2019 (p&lt;0.001). However, no significant difference in mortality rate (1.89% to 2.05%) in this time period was identified. The average age of the population diagnosed with CAA was 50.4 years, which was not significantly different between the study time periods. Comparing races, 62.35% of those with coronary anomalies were white, 17.54% were African American, 12.1% were Hispanic, and 3.11% were Asians or Pacific Islanders. Of note, 4.14% of those with CAA were diagnosed in a rural hospital, 14.68% in an urban non-teaching hospital, and 81.18% in a teaching hospital. This is a significant difference compared to the percentage composition of each hospital within the database. Conclusions: With recent advances in imaging technology, CAA has been detected at earlier stages, allowing for early intervention. However, our study suggests that CAA may still be under diagnosed, given that most were diagnosed at resource heavy teaching hospitals. In addition, the number of minorities diagnosed with CAA increased during the study period, suggesting disparities that exist and will continue to be addressed as access to modern medicine improves. Despite having a low mortality rate, the mortality rate did not improve over the study period. This highlights the need for further studies to identify challenges in diagnosis and management of CAA, especially regarding ethnic and racial disparities.

Differential Utilization Patterns of Total Ankle Arthroplasty vs Arthrodesis: A United States National Ambulatory Database Analysis.

End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States' utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis. TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA. In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA.With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals ("not-for-profit" and "investor-owned") were significantly more likely to offer TAA over AA. Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis. Level III, retrospective cohort study.

Association of Discharge Location Following Pediatric Tracheostomy with Social Determinants of Health: A National Analysis.

To evaluate the breakdown of discharge locations among pediatric tracheostomy patients and determine the impact of demographic variables and social determinants of health. Retrospective review of the 2016 and 2019 Healthcare Cost and Utilization Project Kids' Inpatient Database (HCUP KID). A total of 4000 United States community hospitals, defined as short-term, non-Federal, general, and specialty hospitals. ICD-10-PCS, ICD-10 CM codes, and HCUP data elements were selected for patients and variables of interest. Bivariate comparisons were performed using Rao-Scott Chi-square tests; significance levels in post hoc pairwise testing were adjusted using Bonferroni adjustment. Multinomial generalized logistic regression models were used to determine the average annual odds ratio (OR) of 3 dispositions at discharge relative to discharge home for self-care. Patients aged 11-17, patients from large metropolitan areas, and patients of "Other" race have an increased odds of discharge to a short- or long-term care facility (all P < .001). Weekend admissions, nonelective admissions, patients in Northeast hospitals, and patients at urban nonteaching hospitals are also more likely to be discharged to a short- or long-term care facility (all P < .001). Mean and median total costs of admission were $424,387 and $243,479, respectively, with a median total charge of $854,499. Among pediatric tracheostomy patients, demographic factors that affect discharge disposition include age, community type, and race, and significant hospital factors include day and type of admission, geographic region, and hospital type. Hospitalizations are associated with high overall costs and charges to the patient, which are increasing over time.

Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019

National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.

Temporal trends in the utilization of advanced therapies among patients with acute pulmonary embolism: insights from a national database.

There is a paucity of data regarding the contemporary temporal trends in the adoption of advanced pulmonary embolism (PE) therapies in the United States as well as the parallel trends in outcomes of patients with acute PE. Therefore, we queried the Nationwide Readmissions Database (years 2016-2020) to report the temporal trends in utilization of advanced PE therapies. Our final analysis included 920 770 hospitalizations with acute PE. We demonstrated an increase in the proportion of patients diagnosed with high-risk PE during the study years. Overall, there was an increase in the use of advanced PE therapies, which was mainly due to the increase in the utilization of systemic thrombolytics, and catheter-directed therapies. Also, extracorporeal membrane oxygenation cannulation showed an incremental increase over the study years. The use of inferior vena cava filter has declined, while the use of surgical embolectomy did not change during the study years. The use of advanced therapies has increased among urban teaching, but not among urban non-teaching hospitals. During the study years, there was no change in unadjusted or adjusted in-hospital mortality rates among patients with acute PE, while the 90-day unplanned readmission rate has declined.

Tumor lysis syndrome in solid tumors: A retrospective cohort study of the National Inpatient Sample from 2016 to 2019.

6594 Background: Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency. Patients with a rapidly proliferating tumor or high tumor burden after cytotoxic chemotherapy, predominantly in hematologic malignancies, are at increased risk of TLS. The advancement in therapeutic strategies of oncology in the past few decades has expanded the spectrum of malignancies associated with TLS. A dearth of literature on the incidence of TLS in various solid malignancies exists. Using the National Inpatient Sample (NIS) data, this study aims to highlight the solid malignancies at risk of TLS, highlight the demographic factors, and draw a comparison with that in hematological malignancies. Methods: The NIS 2016-2019 dataset was analyzed utilizing univariate and multivariate logistic regression analysis for the predictors of TLS (P &lt;0.05). StataCorp. 2021. Release 17. College Station, TX: StataCorp LLC, BE version with Stata’s svy command, and appropriate weights, were used to perform the analysis. The overall fit was analyzed using Receiver Operative Curves (ROC), and sensitivity analysis was analyzed using the e-value package. Results: From 2016-2019, a total of 51,385 (48,917-53,853) hospitalizations had an incidence of TLS. We included 16,249 cases of TLS in patients treated for the ten most common malignancies in the US. We found that older age, male sex, and black race were associated with higher odds of TLS. It was reported highest in large hospitals and urban non-teaching hospitals. The regional distribution of the TLS suggests the highest odds in the Western region. The odds of getting TLS were highest among Leukemias and Lymphomas, respectively. Among solid tumors, the odds of getting TLS were highest in uterine cancer patients, followed by lung, breast, pancreatic, and liver cancer among the top five. (Table). Conclusions: In this study, we conclude that solid tumors, mainly uterine, followed by lung and breast, have significantly higher odds of TLS, more so in larger or non-teaching hospitals. There is a need to establish specific management guidelines to prevent these TLS cases that will improve the morbidity and mortality associated with TLS and help build more cost-effective treatment regimens. [Table: see text]

Defining the Price Tag of Complications Following Pancreatic Surgery: A US National Perspective

IntroductionPancreatic surgery tends to have a high rate of postoperative complications due to its complex nature, significantly increasing hospital costs. Our aim was to describe the true association between complications and hospital costs in a national cohort of US patients. MethodsThe National Inpatient Sample was used to conduct a retrospective analysis of elective pancreatic resections performed between 2004 and 2017, categorizing them based on whether patients experienced major complications (MaC), minor complications (MiC), or no complications (NC). Multivariable quantile regression was used to analyze how costs varied at different percentiles of the cost curve. ResultsOf 37,893 patients, 45.3%, 28.6%, and 26.1% experienced NC, MiC, and MaC, respectively. Factors associated with MaC were a Charlson Comorbidity Index of ≥4, prolonged length of stay, proximal pancreatectomy, older age, male sex, and surgery performed at hospitals with a small number of beds or at urban nonteaching hospitals (all P < 0.01). Multivariable quantile regression revealed significant variation in MiC and MaC across the cost curve. At the 50th percentile, MiC increased the cost by $3352 compared to NC while MaC almost doubled the cost of the surgery, increasing it by $20,215 (both P < 0.01). The association between complications and cost was even greater at the 95th percentile, increasing the cost by $10,162 and $108,793 for MiC and MaC, respectively (P < 0.01). ConclusionsMiC and MaC were significantly associated with increased hospital costs. Furthermore, the relationship between MaC and costs was especially apparent at higher percentiles of the cost curve.

Updated Trends in Inferior Vena Cava Filter Use by Indication in the United States After Food and Drug Administration Safety Warnings: A Decade Analysis From 2010 to 2019

Background: Overall inferior vena cava filter (IVCF) utilization has decreased in the United States since the 2010 US Food and Drug Administration (FDA) safety communication. The FDA renewed this safety warning in 2014 with additional mandates on reporting IVCF-related adverse events. We evaluated the impact of the FDA recommendations on IVCF placements for different indications from 2010 to 2019 and further assessed utilization trends by region and hospital teaching status. Methods: Inferior vena cava filter placements between 2010 and 2019 were identified in the Nationwide Inpatient Sample database using the associated International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision codes. Inferior vena cava filter placements were categorized by indication for venous thromboembolism (VTE) “treatment” in patients with VTE diagnosis and contraindication to anticoagulation and “prophylaxis” in patients without VTE. Generalized linear regression was used to analyze utilization trends. Results: A total of 823 717 IVCFs were placed over the study period, of which 644 663 (78.3%) were for VTE treatment and 179 054 (21.7%) were for prophylaxis indications. The median age for both categories of patients was 68 years. The total number of IVCFs placed for all indications decreased from 129 616 in 2010 to 58 465 in 2019, with an aggregate decline rate of −8.4%. The decline rate was higher between 2014 and 2019 than between 2010 and 2014 (−11.6% vs −7.2%). From 2010 to 2019, IVCF placement for VTE treatment and prophylaxis trended downward at rates of −7.9% and −10.2%, respectively. Urban nonteaching hospitals saw the highest decline for both VTE treatment (−17.2%) and prophylactic indications (−18.0%). Hospitals located in the Northeast region had the highest decline rates for VTE treatment (−10.3%) and prophylactic indications (−12.5%). Conclusion: The higher decline rate in IVCF placements between 2014 and 2019 compared with 2010 and 2014 suggests an additional impact of the renewed 2014 FDA safety indications on national IVCF utilization. Variations in IVCF use for VTE treatment and prophylactic indications existed across hospital teaching types, locations, and regions. Clinical Impact Inferior vena cava filters (IVCF) are associated with medical complications. The 2010 and 2014 FDA safety warnings appeared to have synergistically contributed to a significant decline in IVCF utilization rates from 2010 – 2019 in the US. IVC filter placements in patients without venous thromboembolism (VTE) declined at a higher rate than VTE. However, IVCF utilization varied across hospitals and geographical locations, likely due to the absence of universally accepted clinical guidelines on IVCF indications and use. Harmonization of IVCF placement guidelines is needed to standardize clinical practice, thereby reducing the observed regional and hospital variations and potential IVC filter overutilization.

Abstract 47: Outcomes In Acute Ischemic Stroke Patients Treated With Endovascular Thrombectomy Before And After 2015: An Analysis Of The National Inpatient Sample

Background: Endovascular thrombectomy (EVT) demonstrated superiority to medical management in the 2015 trials. We sought to compare outcomes in acute ischemic stroke (AIS) treated with EVT before and after 2015. Methods: A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences &gt;0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for EVT on outcomes. Significance set at an alpha level of &lt;0.001. All analysis performed in R version 4.1.3. Results: A total of 10,415,286 patients with AIS were identified; 149,367 (1.4%) underwent EVT. Among the EVT cohort, 35,562 patients were treated before 2015 (23.8%) vs. 113,805 (76.2%) after. EVT patients after 2015 were more likely to be younger, on private insurance, treated at large urban nonteaching hospitals, had lower Elixhauser Comorbidity Scores (14.71 ± 9.15 vs. 16.21 ± 9.17; p&lt;0.001) but increased markers of stroke severity such as higher rates of ventilator use, paresis, seizures, craniotomy and tracheostomy placement (all p&lt;0.001). After propensity matching, EVT patients after 2015 were more likely to be discharged home (AOR 1.35, 95%CI:1.24-1.47), have increased hospital charges ($40828.79; 95%CI: $36391.76-45265.81), had shorter hospital stay (-0.74 days, 95%CI: -0.99 - -0.48)(all p&lt;0.001), with no difference in In-hospital mortality. Conclusions: This 20-year nationally representative propensity matched analysis of AIS patients shows that outcomes after EVT continue to improve following the landmark 2015 publications, with a higher chance of favorable outcome, lower hospital charge and shorter hospital stay compared to before 2015.