US Hospital Admissions Research Articles

Trends in pathogens among patients hospitalized for pneumonia from 1993 to 2011.

The Nationwide Inpatient Sample aggregated data from approximately 20% of US hospital admissions from 1993 to 2011. Prior literature found that pneumonia admissions decreased following the introduction of the pneumococcal vaccine in 2000.1 The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes provide information regarding pneumonia pathogens, but no studies, to our knowledge, have used these codes to analyze longitudinal trends in the pathogens documented during hospitalizations for pneumonia.

National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011.

The increasing intensity of diabetes mellitus management over the past decade may have resulted in lower rates of hyperglycemic emergencies but higher rates of hospital admissions for hypoglycemia among older adults. Trends in these hospitalizations and subsequent outcomes are not known. To characterize changes in hyperglycemia and hypoglycemia hospitalization rates and subsequent mortality and readmission rates among older adults in the United States over a 12-year period, and to compare these results according to age, sex, and race. Retrospective observational study using data from 33,952,331 Medicare fee-for-service beneficiaries 65 years or older from 1999 to 2011. Hospitalization rates for hyperglycemia and hypoglycemia, 30-day and 1-year mortality rates, and 30-day readmission rates. A total of 279,937 patients experienced 302,095 hospitalizations for hyperglycemia, and 404,467 patients experienced 429,850 hospitalizations for hypoglycemia between 1999 and 2011. During this time, rates of admissions for hyperglycemia declined by 38.6% (from 114 to 70 admissions per 100,000 person-years), while admissions for hypoglycemia increased by 11.7% (from 94 to 105 admissions per 100,000 person-years). In analyses designed to account for changing diabetes mellitus prevalence, admissions for hyperglycemia and hypoglycemia declined by 55.2% and 9.5%, respectively. Trends were similar across age, sex, and racial subgroups, but hypoglycemia rates were 2-fold higher for older patients (≥75 years) when compared with younger patients (65-74 years), and admission rates for both hyperglycemia and hypoglycemia were 4-fold higher for black patients compared with white patients. The 30-day and 1-year mortality and 30-day readmission rates improved during the study period and were similar after an index hospitalization for either hyperglycemia or hypoglycemia (5.4%, 17.1%, and 15.3%, respectively, after hyperglycemia hospitalizations in 2010; 4.4%, 19.9%, and 16.3% after hypoglycemia hospitalizations). Hospital admission rates for hypoglycemia now exceed those for hyperglycemia among older adults. Although admissions for hypoglycemia have declined modestly since 2007, rates among black Medicare beneficiaries and those older than 75 years remain high. Hospital admissions for severe hypoglycemia seem to pose a greater health threat than those for hyperglycemia, suggesting new opportunities for improvement in care of persons with diabetes mellitus.

Outcomes and Costs of Elective Surgery for Diverticular Disease

To compare outcomes and costs of elective surgery for diverticular disease (DD) with those of other diseases commonly requiring colectomy. Multivariable analyses using the Nationwide Inpatient Sample to compare outcomes across primary diagnosis while adjusting for age, sex, race, year of admission, and comorbid disease. A sample of US hospital admissions from 2003-2009. All adult patients (≥18 years) undergoing elective resection of the descending colon or subtotal colectomy who had a primary diagnosis of DD, colon cancer (CC), or inflammatory bowel disease (IBD). In-hospital mortality, postoperative complications, ostomy placement, length of stay, and hospital charges. Of the 74,879 patients, 50.52% had DD, 43.48% had CC, and 6.00% had IBD. After adjusting for other variables, patients with DD were significantly more likely than patients with CC to experience in-hospital mortality (adjusted odds ratio, 1.90; 95% CI, 1.37-2.63; P < .001), develop a postoperative infection (1.67; 1.48-1.89; P < .001), and have an ostomy placed (1.87; 1.65-2.11; P < .001). The adjusted total hospital charges for patients with DD were $6678.78 higher (95% CI, $5722.12-$7635.43; P < .001) and length of stay was 1 day longer (95% CI, 0.86-1.14; P < .001) compared with patients with CC. Patients with IBD had the highest in-hospital mortality, highest rates of complications and ostomy placement, longest length of stay, and highest hospital charges. Despite undergoing the same procedure, patients with DD have significantly worse and more costly outcomes after elective colectomy compared with patients with CC but better than patients with IBD. These relatively poor outcomes should be recognized when considering routine elective colectomy after successful nonoperative management of acute diverticulitis.

Abstract WP398: In-Hospital Mortality: Is the Rate Associated with Hemicraniectomy Changing Over Time?

Introduction: Although there are recent data which suggest that surgical decompression can reduce mortality in patients with acute ischemic stroke (AIS), hemicraniectomy has remained a hot topic in stroke care, with candidates for this procedure at high risk for excessive morbidity and mortality. We determined in-hospital mortality rates for patients with AIS undergoing hemicraniectomy, and compared these rates to those reported previously. Methods: Data from the National Inpatient Sample (NIS), a nationwide administrative database for the year 2009 (&gt;7,800,000 US hospital admissions), and the associated ICD-9-CM diagnosis and procedure codes were used to identify patients. We examined in-hospital mortality associated with hemicraniectomy, with and without thrombolysis in patients admitted emergently, having a discharge diagnosis of acute ischemic stroke and/or precerebral arterial occlusion (multi-level clinical classification software codes 109 and 110). Results: From 114982 adult patients (53% Female) with AIS, 118 (0.1%) underwent hemicraniectomy, and 3115 (2.7%) were treated with thrombolysis. Compared with the nonsurgical group, patients treated with hemicraniectomy were younger (mean age 55 vs. 72 years), but had a higher inpatient mortality rate (25% vs. 7%). In patients treated with thrombolysis, mortality was also higher in the hemicraniectomy group compared to the nonsurgical group (27% vs. 10%). Stroke associated complication rates for systemic sepsis (9% vs. 2%) and aspiration pneumonia (9% vs. 4%) were higher in the hemicraniectomy-treated patients. Median cost per stay was $170,600 in the hemicraniectomy treated patients vs. $25,100 nonsurgical. The 2009 mortality rate in hemicraniectomy-treated patients was lower than previously reported in NIS cohorts from 2000-2006 (25% vs. 32%). Conclusion: In-hospital mortality remains high for patients treated with hemicraniectomy, but appears to have declined from previous years. Despite the fact that candidates for hemicraniectomy are by definition at very high risk for excessive morbidity and mortality, use of databases such as the NIS can supply valuable information on demographics and trends for inpatient outcomes, and the associated costs.

A shifting approach to management of the thoracic aorta in bicuspid aortic valve

The scientific understanding of aortic dilation associated with bicuspid aortic valve (BAV) has evolved during the past 2 decades, along with improvements in diagnostic technology and surgical management. We aimed to evaluate secular trends and predictors of thoracic aortic surgery among patients with BAV in the United States. We used the 1998-2009 Nationwide Inpatient Sample, an administrative dataset representative of US hospital admissions, to identify hospitalizations for adults aged 18 years or more with BAV and aortic valve or thoracic aortic surgery. Covariates included age, gender, year, aortic dissection, endocarditis, thoracic aortic aneurysm, number of comorbidities, hospital teaching status and region, primary insurance, and concomitant coronary artery bypass surgery. Between 1998 and 2009, 48,736 ± 3555 patients with BAV underwent aortic valve repair or replacement and 1679 ± 120 patients with BAV underwent isolated thoracic aortic surgery. The overall number of surgeries increased more than 3-fold, from 4556 ± 571 in 1998/1999 to 14,960 ± 2107 in 2008/2009 (P < .0001). The proportion of aortic valve repair or replacement including concomitant thoracic aortic surgery increased from 12.8% ± 1.4% in 1998/1999 to 28.5% ± 1.6% in 2008/2009, which mirrored an increasing proportion of patients with a diagnosis of thoracic aortic aneurysm. Mortality was equivalent for patients undergoing aortic valve repair or replacement with thoracic aortic surgery and those undergoing isolated aortic valve repair or replacement (1.8% ± 0.3% vs 1.5% ± 0.2%; multivariable odds ratio, 1.02; 95% confidence interval, 0.67-1.57), with decreasing mortality over the study period (from 2.5% ± 0.6% in 1998/1999 to 1.5% ± 0.2% in 2008/2009; multivariable odds ratio per 2-year increment, 0.89; 95% confidence interval, 0.81-0.99; P = .03). Total charges for BAV surgical hospitalizations increased more than 7.5-fold from approximately $156 million in 1998 to $1.2 billion in 2009 (inflation-adjusted 2009 dollars). There was a marked increase in the use of thoracic aortic surgery among patients with BAV.

The National AgeWISE Pilot

AgeWISE is a 6-month nurse residency program designed to prepare hospital nurses to meet the needs of older adults, a population that comprises nearly 50% of all US hospital admissions. The goal of AgeWISE, now being piloted in 12 hospitals in the United States, is to produce a tested and refined national model for building geropalliative care capacity among hospital nurses.

Is There an Increased Risk of Hip Fracture in Multiple Sclerosis (MS)? Analysis of the Nationwide Inpatient Sample (NIS) (P06.201)

Objective: To determine if people with MS have a higher rate of hip fractures and to explore the discharge disposition of MS patients with acute hip fracture. Background Impaired ambulation, frequent falls, and prolonged immobilization combined with the high rate of vitamin D deficiency in people with MS could lead to an increased risk of hip fracture. Design/Methods: Retrospective cohort analysis of 20 years of the NIS (HCUP, AGRQ.gov), a 20% stratified sample of US hospital admissions. Admissions with a primary diagnosis of acute hip fracture were identified, as was the subset with a secondary diagnosis of MS. Indirect adjustment was used to compare the prevalence of MS in this population, to that of the US (Noonan, Neurology, 2002). Because of the large number of records and multiple comparisons, p was set a priori at Results: 0.25% of 1,063,726 hip fracture admissions were for MS. Over the 20 years of this dataset the proportion with MS increased from 0.21% to 0.31%. There was a trend for lesser mortality for MS (0.25 vs. 2.97%, p Conclusions: In this nationwide sample of 20 years of US hospital admissions the rate of hip fracture for people with MS was more than twice predicted. While the risk of falls can be partially mitigated through physical therapy and fractures with vitamin D, bisphosphonates are less effective in pre-menopausal women. Disclosure: Dr. Dubinsky has received personal compensation for activities with Allergan Pharmaceuticals as a speaker.Dr. Dubinsky has received research support from Allergan Pharmaceuticals, Medevation Pharmaceuticals, and NIH. Dr. Bhattacharya has nothing to disclose.

Safety of Video-EEG Monitoring from the National Inpatient Sample (IN5-1.008)

Objective: To determine the rate of injuries and complications associated with prolonged videoEEG. Background VideoEEG monitoring is useful in the diagnosis and classification of epilepsy, diagnosis of non-epileptic seizures, and pre-surgical evaluation of medically intractable epilepsy by provoking events by reduction in anti-epileptic drugs and utilizing provocative measures. Risks of video-EEG monitoring include prolonged seizures, status epilepticus and risks associated with falls from seizures. Little data has been published on the frequency of adverse events occurring during video-EEG monitoring. Previous studies have looked a small numbers of patients at a single institution. Design/Methods: Retrospective cohort analysis of the NIS (ahrq.gov) a 20% stratified sample of all US hospital admissions from 1990 (first full year with ICD9 procedure code for videoEEG) through 2008. Elective admissions with a primary procedure videoEEG were selected using the ICD9 procedure code (8919). Other conditions and complications were determined using combination of ICD9 and Clinical Classification Software (CCS, AHRQ.gov) diagnostic codes. Comparison was made between admissions with a final diagnosis of epilepsy vs. nonepileptic events (NES). Because of multiple comparisons, p was set a priori at Results: 36,930 admissions were identified. Epilepsy was the final diagnosis in 86.56%. Urban teaching hospitals accounted for 91.15% of admissions. Status epilepticus occurred in 0.76%, deep vein thrombosis in 0.55%, urinary tract infection in 0.93%, pneumonia in 0.25%, fractures in 0.34% (there were no hip fractures), falls in 0.08% and depression in 6.69%. There were no cases of acute psychosis. There were no significant differences between those with epilepsy and NES. Conclusions: Over the 19 years examined prolonged videoEEG was quite safe. Rates of injuries and complications were lower than previously reported. Depression was the most frequent adverse event. Future studies should examine psychiatric complications of videoEEG monitoring. Disclosure: Dr. Hammond has nothing to disclose. Dr. Dubinsky has received personal compensation for activities with Allergan Pharmaceuticals as a speaker.Dr. Dubinsky has received research support from Allergan Pharmaceuticals, Medevation Pharmaceuticals, and NIH.

Current National Patterns of Comorbid Diabetes among Acute Ischemic Stroke Patients

Background: Type 2 diabetes rates in the general population have risen with the growing obesity epidemic. Knowledge of temporal patterns and factors associated with comorbid diabetes among stroke patients may enable health practitioners and policy makers to develop interventions aimed at reducing diabetes rates, which may consequently lead to declines in stroke incidence and improvements in stroke outcomes. Methods: Using the Nationwide Inpatient Sample (NIS), a nationally representative data set of US hospital admissions, we assessed trends in the proportion of acute ischemic stroke (AIS) patients with comorbid diabetes from 1997 to 2006. Independent factors associated with comorbid diabetes were evaluated using multivariable logistic regression. Results: Over the study period, the absolute number of AIS hospitalizations declined by 17% (from 489,766 in 1997 to 408,378 in 2006); however, the absolute number of AIS hospitalizations with comorbid type 2 diabetes rose by 27% [from 97,577 (20%) in 1997 to 124,244 (30%) in 2006, p < 0.001]. The rise in comorbid diabetes over time was more pronounced in patients who were relatively younger, Black or ‘other’ race, on Medicaid, or admitted to hospitals located in the South. Factors independently associated with higher odds of diabetes in AIS patients were Black or ‘other’ versus White race, congestive heart failure, peripheral vascular disease, history of myocardial infarction, renal disease and hypertension. Conclusions: Although hospitalizations for AIS in the US decreased from 1997 to 2006, there was a steep rise in the proportion with comorbid diabetes (from 1 in 5 to almost 1 in 3). Specific patient populations may be potential targets for mitigating this trend.

Maternal cardiovascular events during childbirth among women with congenital heart disease

ObjectivesTo define the epidemiology of adverse cardiovascular events among women with congenital heart disease (CHD) hospitalised for childbirth in the USA.Design and settingThe 1998–2007 Nationwide Inpatient Sample, an administrative dataset...

Unexpected Benefits of Rotavirus Vaccination in the United States

The large-scale introduction of a new vaccine can uncover many secrets and surprises about the epidemiology of disease that might not be discovered in any other way. Examination of the outcome of a vaccine introduction can validate prior assumptions concerning the burden of disease and the economic consequences of the vaccination program, as well as determine herd effects of the program arising from either a reduction in the environmental load of the infectious agent or a decrease in the group of susceptibles that might blunt transmission of the agent. In this issue of the Journal, Lopman et al document the impact of the introduction of rotavirus vaccines in the United States and find some surprises that could not have been fully anticipated or predicted in advance [ 1 ]. In 2006, the United States introduced a new rotavirus vaccine that was immediately recommended for the routine immunization of all children [ 2 ]. Uptake was slow at first but by 2008, about 60% of American infants were being immunized. Small local surveys of diarrheal illnesses in children , 2y ears who had been immunized indicated a substantial reduction in hospitalizations and emergency room visits [ 3 ‐ 8 ], outcomes predicted by the large clinical trials that determined the vaccine’s efficacy to be 85% or more against severe disease [ 9 , 10 ]. However, this was not the whole story. Lopman et al at the Centers for Disease Control and Prevention have analyzed al arge database covering approximately 20% of all US hospital admissions and looked at the numbers of discharges coded for diarrhea due to rotavirus or for any unspecified cause among children from 0 to 24 years of age. They compared baseline rates of these hospital discharge records in the prevaccination years, 2000‐2006, versus the postvaccination year 2008, as well as the trend over the 2-year period when the vaccine was being introduced. From this analysis, they have made several remarkable observations on the indirect effects of the vaccine that could not have been anticipated before the vaccine was introduced.

Trends in US Hospital Admissions for Skin and Soft Tissue Infections

Using data from the 2000–2004 US Healthcare Cost and Utilization Project National Inpatient Sample, we found that total hospital admissions for skin and soft tissue infections increased by 29% during 2000–2004; admissions for pneumonia were largely unchanged. These results are consistent with recent reported increases in community-associated methicillin-resistant Staphylococcus aureus infections.

Genetic Nondiscrimination Legislation: A Critical Prerequisite for Pharmacogenomics Data Sharing

Russ B Altman1†, Neal Benowitz2, David Gurwitz3, Jeantine Lunshof4, Mary Relling5, Jatinder Lamba5, Eric Wieben6, Sean Mooney7, Kathleen Giacomini2, Scott Weiss8, Julie A Johnson9, Howard McLeod10, David Flockhart7, Richard Weinshilboum6, Alan R Shuldiner11, Dan Roden12, Ronald M Krauss13 & Mark Ratain14 †Author for correspondence 1Stanford University, Department of Genetics and Bioengineering, Clark S172, Stanford, CA 94305-5444, USA E-mail: Russ.Altman@ stanford.edu 2University of California, San Francisco 3Tel-Aviv University 4VU University Medical Center 5St Jude Children’s Research Hospital 6Mayo Clinic 7Indiana University School of Medicine 8Harvard Medical School 9University of Florida 10University of North Carolina 11University of Maryland 12Vanderbilt School of Medicine 13Children’s Hospital Oakland Research Institute 14University of Chicago On 31st January 2007, the US Senate Health, Education, Labor and Pensions Committee approved the Genetic Information Nondiscrimination Act (GINA) by a vote of 19:2. It was unanimously approved by the US Congress Committee on Education and Labor 2 weeks later. This legislation, aimed at preventing genetic discrimination in employment and insurance [1], will be imperative for protecting altruistic individuals who volunteer for genetic research [2]. There is an emerging consensus among researchers that genetic data must be accessible to individual research participants upon their request [3], while not putting them at risk with respect to their employment, insurance and additional personal aspects [4]. The GINA balances individual freedoms and privacy rights with societal needs for affordable and more effective healthcare and helps to pave the way for more personalized medicine [5]. Indeed, genetic information can be used to improve healthcare, in particular with regard to reducing the alarming rates of adverse drug reactions, which led to 6.7% of all US hospital admissions during 2004–2005 [6], consistent with earlier studies in the UK [7]. Increased use of individual genetic information about drug-metabolizing and drug-target gene alleles as part of healthcare treatment decisions may substantially reduce such morbidity [8]. However, building up the required knowledge depends on the analysis of large individual genotype/phenotype data sets from patient cohorts and requires open data sharing so that large, meaningful and less biased data sets are available to researchers [9]. Lack of open data sharing, in particular between the private and public sectors, hinders our ability to assemble large aggregated data sets [9]. A key obstacle for data sharing is concern about depositing data sets from individual study participants into public databases; some researchers fear they will be held responsible in cases where the data are re-identified (using computational data-mining techniques) and subsequently used (by employers or insurers) to discriminate against study participants. We therefore believe that legislation that offers protection to individuals or groups who share genetic information – against both re-identification and discrimination – is essential for efforts to move genomic medicine into practice. Legislation barring discrimination or stigmatization based on genetic information has been proposed for years, but enactment has become particularly urgent in view of rapidly falling genotyping costs [10], the scope of ongoing genome-wide association studies [11] and the increasing availability of comprehensive personal data in the public domain [4]. We therefore strongly support the current efforts to establish a solid legal framework as a primary means to protect individuals against misuse of their genetic information and as an essential tool for allowing open data sharing in pharmacogenomics.

Treatment With Tissue Plasminogen Activator Is Not Associated With Increased Use of Neurosurgery

Current guidelines of stroke care imply that tissue plasminogen activator (rtPA) should be only used in centers with a neurosurgeon available to manage any intracranial hemorrhage (ICH). Such advice may be difficult to follow with the current US shortage of neurosurgeons. It could also contribute to the underutilization of rtPA in smaller hospitals and might not be justified if, in practice, most ICHs were managed medically. Using the Health Cost Utilization Project 2000 sample we studied the relationship among ischemic stroke, ICH, and rtPA. In this sample of 7,450,992 hospital admissions, 1516 patients had both ischemic stroke and ICH. Among these patients, 58 had received rtPA and 5 of those (8.6%) had a neurosurgical intervention. In the remaining 1458 patients who did not receive rtPA, 178 (12.2%) had neurosurgery. Therefore, the odds ratio for having a neurosurgical intervention for ICH after rtPA was 0.68 (95% confidence interval: 0.27-1.7). In this large sample of US hospital admissions as a result of acute ischemic stroke with overlapping hemorrhage, the use of rtPA was not associated with an increased number of neurosurgical interventions. This lack of association, which needs to be confirmed in prospective studies, argues against withholding treatment with rtPA in patients with stroke based on neurosurgical availability.

Hospital costs associated with bariatric procedures in the United States

Background Weight loss operations are being performed at an exponentially increasing rate. Although highly effective for controlling obesity and its complications, the operations are expensive. The operations are thought to be cost-effective, but there has not been an analysis of the costs associated with these procedures at a national level precluding definitive cost-effectiveness studies useful for policy determination. Methods The 2001 and 2002 National Inpatient Survey (NIS) was used to establish costs attributable to bariatric surgery. This survey contains discharge information for approximately 20% of all US hospital admissions in any given year. Bariatric procedures were identified by ICD-9-CM procedures codes and diagnostic related group (DRG) 288 (operating room [OR] procedures for obesity). Results Of the commonly performed operations, laparoscopic gastric bypass had the lowest hospital charges ($19,794/case) relative to open gastric bypass ($22,313/case) and laparoscopic banding procedures ($25,355/case). Laparoscopic gastric bypass resulted in fewer charges because of a 1-day shorter median length of stay. Discussion These data provide benchmarks for the costs associated with the weight loss procedures commonly performed in the United States. Although laparoscopic gastric bypass is the lease costly approach to bariatric surgery, the fact that costs are lower because of decreased length of stay can be disadvantageous for hospitals reimbursed on a per diem basis.

Enterically infecting viruses: pathogenicity, transmission and significance for food and waterborne infection

Enterically infecting viruses are ubiquitous agents, mostly inducing silent infections. Several are however associated with significant diseases in man from diarrhoea and vomiting to hepatitis and meningitis. These viruses arc drawn from a variety of virus families and have different structures and genetic material, yet all are suited to this means of transmission: Normally they are shed in high numbers (assisting environmental transit) and exhibit great particle stability (permitting survival both outside the body and on passage through the stomach). Human activities particularly associated with food and water processing and distribution have the capacity to influence the epidemiology of these viruses. This review provides a description of viruses spreading by these means, their significance as pathogens and considers their behavior in these human-assisted processes.

Hospitalizations for Tuberculosis in the United States in 2000: Predictors of In-Hospital Mortality

Despite curative therapy, mortality remains high for hospitalized patients with tuberculosis (TB) in the United States. The purpose of this study was to describe the characteristics of hospitalized patients with TB and to identify patient characteristics associated with in-hospital mortality. Using the 2000 Nationwide Inpatient Sample, representing 20% of US hospital admissions, we identified 2,279 hospital admissions with a primary diagnosis of TB (International Classification of Diseases, ninth revision, codes, 010.xx to 018.xx). Mortality was the main outcome measure. Logistic regression analyses were performed including age, gender, race, insurance status, income, Deyo-adapted Charlson comorbidity index (DCI), HIV status, hospital admission source, and hospital characteristics as explanatory variables. A disproportionate number of patients hospitalized with TB were men (64%), nonwhite (72%), lived in areas with median incomes of < $35,000 (50%), and had publicly funded health insurance (49%) or no health insurance (17%). The mortality rate for patients hospitalized for TB was greater than that for non-TB hospital admissions (4.9% vs 2.4%, respectively; p < 0.001). Patients with TB who died during hospitalization were older (mean age, 65.1 vs 49.4 years, respectively; p < 0.001), had greater comorbid illness (DCI, 1.1 vs 0.55, respectively; p < 0.001), required longer hospitalizations (19.9 vs 13.9 days, respectively; p < 0.001), and accumulated substantially higher charges ($79,585 vs $31,610, respectively; p < 0.001) than did patients with TB who were alive at hospital discharge. In a multivariable analysis, older age, comorbid illnesses, and emergency department admissions were independently associated with mortality. The total charges for TB hospitalizations in the United States in 2000 exceeded $385 million. Despite public health efforts, patients who are hospitalized with TB are frequently admitted through emergency care settings, have a high risk of in-hospital mortality, and incur substantial hospital charges. To improve TB health outcomes, more vigorous clinical management and prevention strategies should especially target older patients and those with comorbid medical conditions.