The Impact of Severe Obesity on Hospital Length of Stay

Obesity hypoventilation syndrome is associated with worse in-hospital outcomes in patients with acute myocardial infarction: A nationwide study

BACKGROUND

Obesity hypoventilation syndrome (OHS) is a condition characterized by obesity, daytime hypercapnia, and sleep-disordered breathing. The impact of OHS on outcomes in patients with acute myocardial infarction (AMI) remains poorly understood.

METHODS

We conducted a retrospective analysis using data from the National Inpatient Sample (2016-2020) to evaluate the outcomes of patients with OHS admitted for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI).

RESULTS

Among STEMI and NSTEMI patients, 0.15 % and 0.37 % had OHS, respectively. After adjusting for confounders, OHS was associated with higher odds of in-hospital mortality, cardiac arrest, acute kidney injury, renal replacement therapy, and respiratory failure requiring intubation in NSTEMI patients. In STEMI patients, OHS was associated with higher odds of cardiac arrest, acute kidney injury, and respiratory failure.

CONCLUSION

OHS is associated with worse clinical outcomes in patients admitted with AMI, particularly in those with NSTEMI.

Referrals to Palliative Care Services for Hospitalised COVID-19 Patients: A Systematic Literature Review

BACKGROUND

The increase in the incidence of the coronavirus disease 2019 (COVID-19) led to more hospital admissions and deaths, and coincided with an increased need for palliative care. The new circumstances required palliative care services to be flexible and to develop response strategies.

AIM

To synthesise studies including COVID-19 patients to gain insight into how many patients were referred to hospital-based palliative care services, the characteristics and palliative care needs of these patients and the reasons for referral.

DESIGN

A systematic literature search was conducted in January 2022 using the PubMed, Embase, CINAHL, and PsycInfo databases.

RESULTS

Twenty-seven studies were identified. The results show that in 16% of all COVID-19 inpatients and 55% of all deceased COVID-19 inpatients were referred to a palliative care service. The median time from hospital admission to referral was 4 days and from referral to death was 2 days. COVID-19 inpatients were frequently referred for end-of-life care management (52%), had ≥1 comorbidities (84%), and suffered from shortness of breath/dyspnea (45%).

CONCLUSIONS

The care provided was generally acute, with a high proportion of end-of-life care referrals and a short time period from hospital admission to referral and from referral to death. This highlights the importance of early integration of palliative care into emergency department (ED) care of critically ill patients.

Associations between BMI and hospital resource use in patients hospitalised for COVID-19 in England: a community-based cohort study

BACKGROUND

Excess weight is a major risk factor for severe disease after infection with SARS-CoV-2. However, the effect of BMI on COVID-19 hospital resource use has not been fully quantified. This study aimed to identify the association between BMI and hospital resource use for COVID-19 admissions with the intention of informing future national hospital resource allocation.

METHODS

In this community-based cohort study, we analysed patient-level data from 57 415 patients admitted to hospital in England with COVID-19 between April 1, 2020, and Dec 31, 2021. Patients who were aged 20-99 years, had been registered with a general practitioner (GP) surgery that contributed to the QResearch database for the whole preceding year (2019) with at least one BMI value measured before April 1, 2020, available in their GP record, and were admitted to hospital for COVID-19 were included. Outcomes of interest were duration of hospital stay, transfer to an intensive care unit (ICU), and duration of ICU stay. Costs of hospitalisation were estimated from these outcomes. Generalised linear and logit models were used to estimate associations between BMI and hospital resource use outcomes.

FINDINGS

Patients living with obesity (BMI >30·0 kg/m2) had longer hospital stays relative to patients in the reference BMI group (18·5-25·0 kg/m2; IRR 1·07, 95% CI 1·03-1·10); the reference group had a mean length of stay of 8·82 days (95% CI 8·62-9·01). Patients living with obesity were more likely to be admitted to ICU than the reference group (OR 2·02, 95% CI 1·86-2·19); the reference group had a mean probability of ICU admission of 5·9% (95% CI 5·5-6·3). No association was found between BMI and duration of ICU stay. The mean cost of COVID-19 hospitalisation was £19 877 (SD 17 918) in the reference BMI group. Hospital costs were estimated to be £2736 (95% CI 2224-3248) higher for patients living with obesity.

INTERPRETATION

Patients admitted to hospital with COVID-19 with a BMI above the healthy range had longer stays, were more likely to be admitted to ICU, and had higher health-care costs associated with hospital treatment of COVID-19 infection as a result. This information can inform national resource allocation to match hospital capacity to areas where BMI profiles indicate higher demand.

FUNDING

National Institute for Health Research.

Association of body mass index with morbidity following elective ventral hernia repair

Background

Prior work has linked body mass index (BMI) with postoperative outcomes of ventral hernia repair (VHR), though recent data characterizing this association are limited. This study used a contemporary national cohort to investigate the association between BMI and VHR outcomes.

Methods

Adults ≥ 18 years undergoing isolated, elective, primary VHR were identified using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI. Restricted cubic splines were utilized to ascertain the BMI threshold for significantly increased morbidity. Multivariable models were developed to evaluate the association of BMI with outcomes of interest.

Results

Of ~89,924 patients, 0.5 % were considered Underweight, 12.9 % Normal Weight, 29.5 % Overweight, 29.1 % Class I, 16.6 % Class II, 9.7 % Class III, and 1.7 % Superobese. After risk adjustment, class I (Adjusted Odds Ratio [AOR] 1.22, 95 % Confidence Interval [95%CI]: 1.06-1.41), class II (AOR 1.42, 95%CI: 1.21-1.66), class III obesity (AOR 1.76, 95%CI: 1.49-2.09) and superobesity (AOR 2.25, 95 % CI: 1.71-2.95) remained associated with increased odds of overall morbidity relative to normal BMI following open, but not laparoscopic, VHR. A BMI of 32 was identified as the threshold for the most significant increase in predicted rate of morbidity. Increasing BMI was linked to a stepwise rise in operative time and postoperative length of stay.

Conclusion

BMI ≥ 32 is associated with greater morbidity following open, but not laparoscopic VHR. The relevance of BMI may be more pronounced in open VHR and must be considered for stratifying risk, improving outcomes, and optimizing care.

Key message

Body mass index (BMI) continues to be a relevant factor in morbidity and resource use for elective open ventral hernia repair (VHR). A BMI of 32 serves as the threshold for significant increase in overall complications following open VHR, though this association is not observed in operations performed laparoscopically.

Exploring Overnutrition, Overweight, and Obesity in the Hospital Setting-A Point Prevalence Study

Malnutrition is an international healthcare concern associated with poor patient outcomes, increased length of stay, and healthcare costs. Although malnutrition includes both under and overnutrition, there is a large body of evidence that describes the impacts of undernutrition with limited data on overnutrition in hospitalized patients. Obesity itself is a modifiable risk factor associated with hospital-associated complications. However, there is limited reporting of the prevalence of obesity in hospitals. This one-day cross-sectional study (n = 513) captures the prevalence of both under and overnutrition in a hospitalized population and explores dietetic care provided compared to the Nutrition Care Process Model for hospitalized patients who have obesity. The main findings were: (1) the largest proportion of patients were in the overweight and obese classifications (57.3%, n = 294/513); 5.3% of these patients had severe obesity (class III); (2) patients who were overweight and obese had lower malnutrition risk profiles as well as the prevalence of malnutrition; (3) 24.1% of patients who had obesity (n = 34/141) were receiving dietetic intervention; (4) 70.6% (n = 24/34) did not have a nutrition diagnosis that followed the Nutrition Care Process Model. Study results provide valuable clinical insight into the prevalence of overnutrition and opportunities to improve nutrition care for this vulnerable patient group.

Common procedures and conditions leading to inpatient hospital admissions in adults with and without diabetes from 2015 to 2019 in Germany : A comparison of frequency, length of hospital stay and complications

OBJECTIVE

To evaluate common surgical procedures and admission causes in inpatient cases with diabetes in Germany between 2015 and 2019 and compare them to inpatient cases without diabetes.

METHODS

Based on the German diagnosis-related groups (G-DRG) statistics, regression models stratified by age groups and gender were used to calculate hospital admissions/100,000 individuals, hospital days as well as the proportion of complications and mortality in inpatient cases ≥ 40 years with or without a documented diagnosis of diabetes (type 1 or type 2).

RESULTS

A total of 14,222,326 (21%) of all inpatient cases aged ≥ 40 years had a diagnosis of diabetes. More middle-aged females with vs. without diabetes/100,000 individuals [95% CI] were observed, most pronounced in cases aged 40-< 50 years with myocardial infarction (305 [293-319] vs. 36 [36-37], p < 0.001). Higher proportions of complications and longer hospital stays were found for all procedures and morbidities in cases with diabetes.

CONCLUSION

Earlier hospitalizations, longer hospital stays and more complications in inpatient cases with diabetes together with the predicted future increase in diabetes prevalence depict huge challenges for the German healthcare system. There is an urgent need for developing strategies to adequately care for patients with diabetes in hospital.

Goals of Care, Critical Care Utilization and Clinical Outcomes in Obese Patients Admitted under General Medicine

Obesity is associated with long-term morbidity and mortality, but it is unclear if obesity affects goals of care determination and intensive care unit (ICU) resource utilization during hospitalization under a general medicine service. In a cohort of 5113 adult patients admitted under general medicine, 15.3% were obese. Patients with obesity were younger and had a different comorbidity profile than patients who were not obese. In age-adjusted regression analysis, the distribution of goals of care categories for patients with obesity was not different to patients who were not obese (odds ratio for a lower category with more limitations, 0.94; 95% confidence interval [CI]: 0.79-1.12). Patients with obesity were more likely to be directly admitted to ICU from the Emergency Department, require more ICU admissions, and stayed longer in ICU once admitted. Hypercapnic respiratory failure and heart failure were more common in patients with obesity, but they were less likely to receive mechanical ventilation in favor of non-invasive ventilation. The COVID-19 pandemic was associated with 16% higher odds of receiving a lower goals of care category, which was independent of obesity. Overall hospital length of stay was not affected by obesity. Patients with obesity had a crude mortality of 3.8 per 1000 bed-days, and age-adjusted mortality rate ratio of 0.75 (95% CI: 0.49-1.14) compared to patients who were not obese. In conclusion, there was no evidence to suggest biased goals of care determination in patients with obesity despite greater ICU resource utilization.

Healthcare Service Interventions to Improve the Healthcare Outcomes of Hospitalised Patients with Extreme Obesity: Protocol for an Evidence and Gap Map

Hospitalised patients with extreme obesity have poorer healthcare outcomes compared to normal weight patients. How hospital services are coordinated and delivered to meet the care needs of patients with extreme obesity is not well understood. The aim of the proposed evidence gap map (EGM) is to identify and assess the available evidence on healthcare interventions to improve healthcare outcomes for hospitalised patients with extreme obesity. This research will use standardised evidence gap map methods to undertake a five-stage process to develop an intervention-outcome framework; identify the current evidence; critically appraise the quality of the evidence, extract, code, and summarise the data in relation to the EGM objectives; and create a visualisation map to present findings. This EGM will provide a means of determining the nature and quality of health service initiatives available, identify the components of the services delivered and the outcome measures used for evaluation, and will identify areas where there is a lack of research that validates the funding of new research studies.

The Impact of Morbid Obesity on the Health Outcomes of Hospital Inpatients: An Observational Study

Morbid obesity poses a significant burden on the health-care system. This study determined whether morbid obesity leads to worse health-outcomes in hospitalised patients. This retrospective-study examined nutritional data of all inpatients aged 18-79 years, with a body-mass-index (BMI) ≥ 18.5 kg/m² admitted over a period of 4 years at two major hospitals in Australia. Patients were divided into 3 groups for comparison: normal/overweight (BMI 18.5-29.9 kg/m²), obese (BMI 30-39.9 kg/m²) and morbidly-obese (BMI ≥ 40 kg/m²). Outcome measures included length-of-hospital-stay (LOS), in-hospital mortality, and 30-day readmissions. Multilevel-mixed-effects regression was used to compare clinical outcomes between the groups after adjustment for potential confounders. Of 16,579 patients, 1004 (6.1%) were classified as morbidly-obese. Morbidly-obese patients had a significantly longer median (IQR) LOS than normal/overweight patients (5 (2, 12) vs. 5 (2, 11) days, p value = 0.012) and obese-patients (5 (2, 12) vs. 5 (2, 10) days, p value = 0.036). After adjusted-analysis, morbidly-obese patients had a higher incidence of a longer LOS than normal/overweight patients (IRR 1.04; 95% CI 1.02-1.07; p value < 0.001) and obese-patients (IRR 1.13; 95% CI 1.11-1.16; p value < 0.001). Other clinical outcomes were similar between the different groups. Morbid obesity leads to a longer LOS in hospitalised patients but does not adversely affect other clinical outcomes.

Impact of a hospital-wide computerised approach to optimise the quality of antimicrobial prescriptions in patients with severe obesity: a quasi-experimental study

Background

Rates of adherence to available recommendations for dose adjustments in patients with severe obesity are generally low. Hence, antimicrobials are often underdosed in these patients. Antimicrobial stewardship programmes can improve the use of antimicrobials in hospitalised patients. The aim of the study was to analyse the impact of an antimicrobial stewardship programme based on a computerised clinical decision support system for optimal dosing and antimicrobial use in inpatients with severe obesity.

Methods

This quasi-experimental retrospective study using interrupted time series was conducted in an academic centre in Canada from August 2008 to June 2018. The Antimicrobial Prescription Surveillance System was implemented in August 2010 (intervention 1) and specific rules targeting patients with class III obesity (body mass index ≥ 40 kg/m²) were added in June 2014 (intervention 2). Data were collected from all hospitalised adults receiving antimicrobials which required dose adjustment for severe obesity and were stratified by body mass index. Segmented regression analysis of interrupted time series was used to evaluate the impact of the Antimicrobial Prescription Surveillance System on the proportion of inappropriate days of therapy according to posology and on antimicrobial consumption.

Results

Overall, 65 205 antimicrobial prescriptions (68% non-obese, 25% class I-II obesity, and 7% class III obesity) were analysed. In patients with class III obesity, the intervention was associated with a decrease in the proportion of inappropriate days of therapy (trend after the first intervention, −0.8% per 2-month period [95% CI −1.1 to −0.5], p < 0.001; intercept, 11.3% [95% CI 8.2 to 14.5], p < 0.001), which led to a reduction of 35% over an eight-year period (from pre-intervention level of 19.1%). Intervention 1 resulted in a downward trend in antimicrobial consumption, followed by an increasing trend after intervention 2. In these patients, the most frequent interventions made by pharmacists targeted posology (46%).

Conclusions

Antimicrobial Prescription Surveillance System had a positive impact on dosing optimisation and antimicrobial consumption in patients with class III obesity. Improving antimicrobial prescriptions in these patients is important because suboptimal dosing could be associated with unfavourable outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06682-8.

Obesity: is it an additional risk factor in analyzing surgical outcomes in the South Indian population?

Aim

This study aims to determine whether obesity impacts surgical outcomes among patients undergoing surgery at the Surgery Unit in a tertiary care hospital.

Methods

This is a retrospective study. Data were retrieved from the medical records of patients who underwent surgery at a tertiary care hospital. Patient demographics, co-morbidities, intraoperative and postoperative pain scores and complications, if occurring, were compiled for each patient. Patients were subdivided into four subsets based on their disease profile. Each subset was divided into two groups based on their body mass index (BMI). Preoperative BMI greater than or equal to 25 kg/m² was classified as obese.

Results

The study showed that there is a considerable increase in the duration of surgery in obese when compared to non-obese. 30 days readmission rate was higher among obese in all the subsets. We find that in the subset of non-infective conditions, post operative pain mean ranking score is greater among obese (128.8 vs 109.6).

Conclusions

In conclusion, the impact of obesity resulted in increased duration of surgery and post-operative pain. The association between obesity and surgical outcome shows the importance to further research to find a way to prevention of some of the complications of surgery that could occur in patients with high BMI.

Obesity Trends Amongst Hospitalized Patients with Spinal Cord Stimulator Implants

INTRODUCTION

Chronic pain remains an important public health problem as it continues to increase healthcare-related cost. Comorbidities like obesity have been associated with efficacy of spinal cord stimulator (SCS) therapy and worse outcomes. The goal of this study is to investigate the trends of obesity amongst hospitalized patients with SCS therapy as well as healthcare utilization outcomes.

METHODS

Using the International Classification of Diseases (ICD) ninth and tenth procedure and diagnosis code, we investigated the National Inpatient Sample (NIS) for patients with SCS implants between 2011 and 2015. Patients received a diagnosis of obesity based on the following categories: class I, II and III obesity. Age, gender, and comorbid conditions of patients with obesity were matched 1:1 on propensity score to those without obesity diagnosis. Our primary outcome was defined as trend of obesity diagnosis. Our secondary outcome, healthcare utilization, included in-hospital cost, length of stay, and discharge location.

RESULTS

Between 2011 and 2015, a total of 3893 patients with SCS implants were identified (average age 56 ± 15 years, 58% female, 0.70 ± 1.1 Charlson Comorbidity Index, CCI). Of this cohort, 640 patients were identified as obese. The proportion of patients with obesity diagnosis increased significantly from 13.75% in 2011 to 19.36% in 2015 (p < 0.001). After 1:1 matching on propensity score, 597 patients with obesity were successfully matched to 597 patients without obesity. The total hospital cost for SCS patients with obesity (median $104,845, IQR $74,648-144,292) was not significantly different from patients without obesity diagnosis (median $111,092, IQR $68,990-145,459) (p = 0.161).

CONCLUSIONS

The data from our study suggests that there is an increasing rate of obesity diagnosis amongst patients with SCS therapy. However, there was no difference in healthcare utilization between patients with and without obesity. Additional studies may provide more insight into our findings.

The impact of bariatric surgery on in-patient clinical outcomes among patients with autoimmune hepatitis

Autoimmune hepatitis (AIH) is a form of liver inflammation in which immune cells target hepatocytes, inducing chronic inflammatory states. Bariatric surgery (BS) was shown to reduce inflammation in severely obese patients. We hypothesize that obese patients with AIH and BS have lower prevalence of liver-related complications and in-patient mortality compared to those without BS.The National Inpatient Sample from 2007 to 2013 was queried for hospitalizations of adults over 18 years of age with a diagnosis of AIH. Of those, hospitalizations with BS were selected as cases and those with morbid obesity as controls. Case-control 1:2 matching was done based on sex, age, race, and comorbidities. Primary outcomes were prevalence of liver-related complications and in-patient mortality. Independent risk factors of in-patient clinical outcomes were identified using multivariate regression analysis.From 137,834 hospitalizations with a diagnosis of AIH, 688 with BS were selected as cases, and 1295 were matched as controls. The prevalence of ascites was higher in the BS group compared to the control (odds ratio 1.73, 95% confidence interval (CI) 1.27-2.36). The prevalence of cirrhosis (36.8% vs 33.2%), portal hypertension (7.4% vs 10.0%), hepatic encephalopathy (10.6% vs 8.7%), and varices and variceal bleeding (3.9% vs 5.5%) was not statistically different from case controls, (P > .05).BS was an independent risk factor for ascites (adjusted odds ratio (aOR) 1.87; 95% CI 1.36-2.56) and hepatic encephalopathy (aOR 1.42; 95% CI 1.03-1.97) but was an independent protective factor against in-patient mortality (aOR 0.21, 95% CI 0.08-0.55) once adjusted for age, sex, race, and comorbidities.

The Association between High Body Mass Index and Early Clinical Outcomes in Patients with Proximal Femur Fractures

BACKGROUND

Fractures of the proximal femur constitute daily work in orthopedic trauma surgery. With the continuous increase of obesity in the general population, surgeons face several known technical challenges. The aim of this study was to investigate the association of high body mass index (BMI) in patients with proximal femur fractures with intra- and postoperative adverse events, as well as with functional outcomes after successful surgery.

METHODS

In this retrospective, single-center cohort study, 950 patients who sustained a fracture of the proximal femur (femoral neck fracture or trochanteric fracture) and underwent surgical treatment at our level I trauma center between 2003 and 2015 were included. Patient-specific data were obtained in regard to demographics, comorbidities, and fracture morphology. In-hospital postoperative complications (i.e., need for revision surgery, wound site infection, pneumonia, urinary tract infection, necessary transfusion, and deep-vein thrombosis) were analyzed, along with the length of hospitalization and overall mortality rate. Functional outcome was assessed using the Barthel index and the patient's ability to walk on crutches. Mortality rate and need for revision surgery were assessed over a two-year time period. Any adverse event was correlated to one of the four WHO's BMI groups.

RESULTS

The cohort included 80 (8.4%) underweight patients, 570 (60.0%) normal weight patients, 241 (25.4%) overweight patients, and 59 (6.2%) obese patients. We found more femoral neck fractures (506, or 53%) than trochanteric fractures (444, or 47%). In bivariate analysis, no significant difference was found in regard to overall mortality or postoperative complications. Hospitalization time (LOS) differed between the underweight (12.3 ± 4.8 days), normal (13.6 ± 7.8 days), overweight (14.2 ± 11.7 days), and obese patients (16.0 ± 9.7 days) (p = 0.040). Operation time increased stepwise with increasing BMI: underweight = 85.3 ± 42.9 min; normal weight = 90.2 ± 38.2 min; overweight = 99.9 ± 39.9 min; obese = 117.2 ± 61.5 min (p < 0.001). No significant difference was found by analyzing functional outcomes. However, patients with intermediate BMI levels (18.5-30 kg/m2) tended to achieve the best results, as represented by a higher Barthel index score and the patient's ability to walk on crutches.

CONCLUSION

Increased BMI in patients with proximal femur fractures is associated with both longer operation time and length of hospitalization (LOS). Postoperative mobilization and functional outcomes appear to follow a reversed J-curve distribution (with overweight patients showing the best functional results), whereas both obese and underweight patients have associated poorer function.

The medical care costs of obesity and severe obesity in youth: An instrumental variables approach

This paper is the first to use the method of instrumental variables to estimate the impact of obesity and severe obesity in youth. on U.S. medical care costs. We examine data from the Medical Expenditure Panel Survey for 2001-2015 and instrument for child BMI using the BMI of the child's biological mother. Instrumental variables estimates indicate that obesity in youth raises annual medical care costs by $907 (in 2015 dollars) or 92%, which is considerably higher than previous estimates of the association of youth obesity with medical costs. We find that obesity in youth significantly raises costs in all major categories of medical care: outpatient doctor visits, inpatient hospital stays, and prescription drugs. The costs of youth obesity are borne almost entirely by third-party payers, which is consistent with substantial externalities of youth obesity, which in turn represents an economic rationale for government intervention.

Impact of Obesity on Surgical Outcomes Following Laminectomy for Spinal Metastases

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To determine the effect of obesity (body mass index >30 kg/m²) on perioperative morbidity and mortality after surgical decompression of spinal metastases.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database is a large multicenter clinical registry that collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent decompression with laminectomy for treatment of metastatic spinal lesions between 2010 and 2014. Patients were separated into 2 cohorts based on the presence of absence of obesity. Univariate analysis and multivariate logistic regression analysis were used to analyze the effect of obesity on perioperative morbidity and mortality.

RESULTS

There was a significantly higher rate of venous thromboembolism (VTE; obese 6.6% vs nonobese 4.2%; P = .01) and pulmonary complications (obese 2.6% vs nonobese 2.2%; P = .046) in the obese group compared with the nonobese group. The nonobese group had prolonged hospitalization (obese 62.0% vs nonobese 69.0%; P = .001) and a higher incidence of blood transfusions (obese 26.8% vs nonobese 34.2%; P < .001). On multivariate analysis, obesity was found to be an independent risk factor for VTE (odds ratio = 1.75, confidence interval = 1.17-2.63, P = .007).

CONCLUSIONS

Obese patients were predisposed to an elevated risk of VTE following laminectomy for spinal metastases. Early postoperative mobilization and a low threshold to evaluate for perioperative VTE are important in these patients in order to appropriately diagnose and treat these complications and minimize morbidity.

Association Between Obesity and Acute Severity Among Patients Hospitalized for Asthma Exacerbation

BACKGROUND

Although studies have demonstrated relations between obesity and incident asthma, little is known about the association of obesity with acute severity in adults hospitalized for asthma exacerbation.

OBJECTIVES

To investigate the association of obesity with acute severity of asthma exacerbation.

METHODS

This is a retrospective cohort study using population-based data of 8 geographically diverse US states from 2010 through 2013. We included adults (age 18-54 years) hospitalized for asthma exacerbation. The outcome measures were markers of acute severity-use of mechanical ventilation (defined by noninvasive positive pressure ventilation and/or invasive mechanical ventilation) and hospital length of stay. To determine the association of obesity with each outcome, we fit multivariable models adjusting for patient-level confounders (eg, age, sex, race/ethnicity, primary insurance, quartiles for household income, residential status, and comorbidities) and potential patient clustering within hospitals.

RESULTS

Among the 72,086 patients hospitalized for asthma exacerbation, 24% were obese. Obesity was associated with a significantly higher risk of any mechanical ventilation use (8.3% vs 5.0%; adjusted odds ratio [OR], 1.77; 95% CI, 1.63-1.92; P < .001) driven by the higher risk of noninvasive positive pressure ventilation use (7.2% vs 3.4%; adjusted OR, 2.14; 95% CI, 1.96-2.35; P < .001). Likewise, obese patients were more likely to have a hospital length of stay of 3 or more days compared with nonobese patients (59.4% vs 46.5%; adjusted OR, 1.37; 95% CI, 1.32-1.43; P < .001). These findings were consistent with stratifications by age, sex, and race/ethnicity.

CONCLUSIONS

In this population-based study of adults hospitalized for asthma exacerbation, obesity was associated with higher acute severity.

Hospital costs in relation to body-mass index in 1·1 million women in England: a prospective cohort study

BACKGROUND

Excess weight is associated with poor health and increased health-care costs. However, a detailed understanding of the effects of excess weight on total hospital costs and costs for different health conditions is needed.

METHODS

Women in England aged 50-64 years were recruited into the prospective Million Women Study cohort in 1996-2001 through 60 NHS breast cancer screening centres. Participants were followed up and annual hospital costs and admission rates were estimated for April 1, 2006, to March 31, 2011, in relation to body-mass index (BMI) at recruitment, overall and for categories of health conditions defined by the International Classification of Diseases 10th revision chapter of the primary diagnosis at admission. Associations of BMI with hospital costs were projected to the 2013 population of women aged 55-79 years in England.

FINDINGS

1 093 866 women who provided information on height and weight, had a BMI of at least 18·5 kg/m2, and had no previous cancer at recruitment, were followed up for an average of 4·9 years from April 1, 2006 (12·3 years from recruitment), during which time 1·84 million hospital admissions were recorded. Annual hospital costs were lowest for women with a BMI of 20·0 kg/m2 to less than 22·5 kg/m2 (£567 per woman per year, 99% CI 556-577). Every 2 kg/m2 increase in BMI above 20 kg/m2 was associated with a 7·4% (7·1-7·6) increase in annual hospital costs. Excess weight was associated with increased costs for all diagnostic categories, except respiratory conditions and fractures. £662 million (14·6%) of the estimated £4·5 billion of total annual hospital costs among all women aged 55-79 years in England was attributed to excess weight (BMI ≥25 kg/m2), of which £517 million (78%) arose from hospital admissions with procedures. £258 million (39%) of the costs attributed to excess weight were due to musculoskeletal admissions, mainly for knee replacement surgeries.

INTERPRETATION

Excess body weight is associated with increased hospital costs for middle-aged and older women in England across a broad range of conditions, especially knee replacement surgery and diabetes. These results provide reliable up-to-date estimates of the health-care costs of excess weight and emphasise the need for investment to tackle this public health issue.

FUNDING

Cancer Research UK; Medical Research Council; National Institute for Health Research.

Clinical outcomes for the obese hospital inpatient: An observational study

OBJECTIVES

The prevalence of obesity presents a burden for Australian health care. The aim of this study was to determine whether severely obese hospital inpatients have worse outcomes.

METHODS

This is an observational cohort study, using data from all adult patients admitted to hospital for all elective and emergency admissions of patients aged over 18 years to two large Australian urban hospitals. We measured their length of stay, intensive care unit admission rate, intensive care unit length of stay, mortality and readmission rates within 28 days of discharge and compared these outcomes in the severely obese and non-severely obese subjects using t-test or chi-square test as appropriate.

RESULTS

Between February 2008 and February 2012, 120,872 were admitted to hospital 193,800 times; 2701 patients were identified as severely obese (2.23%) and 118,171 patients were non-severely obese. If admitted as an emergency, severely obese patients have worse outcomes and consume more resources than other patients. These outcomes are still worse, but less so, if the obese patient is admitted as an elective patient suggesting that anticipation of any obesity-specific problems can have a beneficial effect.

CONCLUSION

Upon admission or discharge of severely obese hospital inpatients, health care plans should be even more carefully laid than usual to reduce the risk of readmission.

The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study

BACKGROUND

Obesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use and Medicare expenditures is unknown.

OBJECTIVE

To describe the associations between body mass index (BMI) and hospice use and Medicare expenditures in the last 6 months of life.

DESIGN

Retrospective cohort.

SETTING

The HRS (Health and Retirement Study).

PARTICIPANTS

5677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012.

MEASUREMENTS

Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death. Body mass index was modeled as a continuous variable with a quadratic functional form.

RESULTS

For decedents with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3% (95% CI, 36.5% to 40.2%), hospice duration was 42.8 days (CI, 42.3 to 43.2 days), probability of in-home death was 61.3% (CI, 59.4% to 63.2%), and total Medicare expenditures were $42 803 (CI, $41 085 to $44 521). When BMI increased to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (CI, -9.3 to -4.0 percentage points), hospice duration decreased by 3.8 days (CI, -4.4 to -3.1 days), probability of in-home death decreased by 3.2 percentage points (CI, -6.0 to -0.4 percentage points), and total Medicare expenditures increased by $3471 (CI, $955 to $5988). For morbidly obese decedents (BMI ≥40 kg/m2), the predicted probability of hospice enrollment decreased by 15.2 percentage points (CI, -19.6 to -10.9 percentage points), hospice duration decreased by 4.3 days (CI, -5.7 to -2.9 days), and in-home death decreased by 6.3 percentage points (CI, -11.2 to -1.5 percentage points) versus decedents with BMI of 20 kg/m2.

LIMITATION

Baseline data were self-reported, and the interval between reported BMI and time of death varied.

CONCLUSION

Among community-dwelling decedents in the HRS, increasing obesity was associated with reduced hospice use and in-home death and higher Medicare expenditures in the last 6 months of life.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation Clinical Scholars Program.

Do acute hospitalised patients in Australia have a different body mass index to the general Australian population: a point prevalence study?

Objective The aim of the present study was to provide a current snapshot of the body mass index (BMI) of the entire patient cohort of an Australian tertiary hospital on one day and compare these data with current published Australian and state (Western Australia) population norms. Methods A single-centre prospective point prevalence study was performed whereby BMI was calculated following actual measurement of patient weight (nurse) and height (physiotherapist) on one day during 2015. Variables were summarised descriptively, and one-way analysis of variance was used to investigate the relationship between continuous BMI and hospital speciality. Multivariate Cox proportional hazards regression was used to analyse the time to leaving hospital, where those who died were censored at their date of death. Results Data were collected from 416 patients (96% of the hospital population on that day). The mean (± s.e.m.) BMI across the whole hospital population was 26.6±2.2kgm-2, with 37% of patients having normal BMI, 8% being underweight, 32% being overweight, 19% being obese and 4% being severely obese. Comparison with both national and state population norms for 2014-15 reflected higher proportions of the hospital population in the underweight and extremely obese categories, and lower proportions in the overweight and obese categories. There was no significant difference in BMI across medical specialties. Conclusions Despite health warnings about the direct relationship between illness and being overweight or obese, the results of the present study reveal fewer hospitalised patients in these BMI categories and more underweight patients than in the non-hospitalised general Australian population. Being overweight or obese may offer some protection against hospitalisation, but there is a point where the deleterious effect of obesity results in more extremely obese individuals being hospitalised than the proportion represented in the general population. What is known about the topic? Although there is significant current published data relating to general Australian population BMI, there is little pertaining specifically to the hospitalised population. Accordingly, although we know that as an affluent Western country we are seeing growing rates of overweight and obese people and relatively few underweight or undernourished people in the general population, we do not know whether these trends are mirrored or magnified in those who are sick in hospital. We also know that although caring for obese patients carries a significant burden, there is the suggestion in some healthcare literature of an 'obesity paradox', whereby in certain disease states being overweight actually decreases mortality and promotes a faster recovery from illness compared with underweight people, who have poorer outcomes. What does this paper add? This paper is the first of its kind to actually measure and calculate the BMI of a whole tertiary Australian hospital population and provide some comparison with published Australian norms. On average, the hospital cohort was overweight, with a mean (± s.e.m.) BMI of 26.6±2.2kgm-2, but less so than the general population, which had a mean BMI of 27.5±0.2kgm-2. The results also indicate that compared with state and national norms, underweight and extremely obese patients were over-represented in the hospitalised cohort, whereas overweight or obese patients were under-represented. What are the implications for practitioners? Although only a single-centre study, the case-mix and socioeconomic catchment area of the hospital evaluated in the present study suggest that it is a typical tertiary urban West Australian facility and, as such, there may be some implications for practitioners. Primarily, administrators need to ensure that we are able to accommodate people of increasing weight in our hospital facilities and have the resources with which to do so, because, on average, hospitalised patients were overweight. In addition, resources need to be available for managing the extremely obese if numbers in this subset of the population increase. Finally, practitioners may also need to consider that although the management of underweight and undernourished patients may be less of a physical burden, there are actually more of these patients in hospital compared with the general population, and they may require a different package of resource utilisation.

Obesity Is Associated With Increased Morbidity in Moderate to Severe COPD

BACKGROUND

Obesity is prevalent in the United States; however, the impact of obesity on COPD morbidity is unclear. We hypothesized that obesity is associated with worse outcomes in COPD.

METHODS

We examined 3,631 participants from the multicenter prospective cohort study Genetic Epidemiology of COPD (COPDGene) who had spirometry-confirmed COPD, a postbronchodilator FEV₁ < 80% predicted, and a BMI ≥ 18.5 kg/m². We conducted logistic and linear regression analyses to determine the association between COPD outcomes and obesity class, adjusting for relevant confounders. The referent for obesity classes included normal/overweight individuals (BMI range, 18.5-29.9 kg/m²).

RESULTS

Overall, 35% of participants were obese, with 21% class I (BMI range, 30-34.9 kg/m²), 9% class II (BMI range, 35-39.9 kg/m²), and 5% class III (BMI ≥ 40 kg/m²). The number of comorbidities increased with increasing obesity class (P < .001). Increasing obesity class was independently associated with worse respiratory-specific and general quality of life (QOL) (St. George's Respiratory Questionnaire score and Short Form-36 score version 2, respectively), reduced 6-min walk distance (6MWD), increased dyspnea (Modified Medical Research Council score ≥ 2), and greater odds of severe acute exacerbation of COPD (AECOPD). The associations between obesity and worse outcomes were independent of the presence of comorbidities, except in the case of SF-36 and severe exacerbations.

CONCLUSIONS

Obesity is prevalent among individuals with COPD and associated with worse COPD-related outcomes, ranging from QOL and dyspnea to 6MWD and severe AECOPD. These associations were strengthened when obesity was analyzed as a dose-dependent response. Obesity in patients with COPD may contribute to a worse COPD-related course.

Prevalence of obesity and the effect on length of mechanical ventilation and length of stay in intensive care patients: A single site observational study

OBJECTIVES

To provide a snapshot of the prevalence of abnormal body mass index (BMI) in a sample of intensive care unit (ICU) patients; to identify if any medical specialty was associated with abnormal BMI and to explore associations between BMI and ICU-related outcomes.

BACKGROUND

Obesity is an escalating public health issue across developed nations but there is little data pertaining to critically ill patients who require care that is expensive.

METHODS

Retrospective observational audit of 735 adult patients (median age 58 years) admitted to the Sir Charles Gairdner Hospital 23 bed tertiary ICU between November 2012 and June 2014. Primary outcome measure was patient BMI: underweight (<18.5kg/m²), normal weight (18.5-24.99kg/m²), overweight (25-29.99kg/m²), obese (30-39.99kg/m²) or extreme obese (40kg/m² or above). Other measures included gender, acute physiology and chronic health evaluation II score, admission specialty, length of mechanical ventilation (MV), length of stay (LOS) and mortality.

RESULTS

Compared to the general population there was a higher proportion of obese patients within the cohort with the majority of patients overweight (33.9%) or obese (36.5%) and median BMI of 27.9 (IQR 7.9). There were no significant differences between specialties for BMI (p=0.103) and abnormal BMI was not found to impact negatively on mortality (ICU, p=0.373; hospital, p=0.330). Normal BMI patients had shorter length of MV than other BMI categories and the impact of BMI on ICU LOS was dependent on length of MV. Overweight patients ventilated for five days or more had a shorter LOS, and extremely obese non-ventilated patients had a longer LOS, compared to normal weight patients.

CONCLUSIONS

Although the obesity-disease relationship is increasingly complex and data presented reflects categorical BMI for patients admitted to a single ICU site it may be important to consider the cost implications of caring for this cohort especially with regard to MV and LOS.

Association between body mass index and in-hospital outcomes: Analysis of the nationwide inpatient database

IMPORTANCE

Over one-third of American adults (36%) are obese and more than two-thirds (69%) are overweight. The impact of obesity on hospitalization outcomes is not well understood.

OBJECTIVE

To examine the association between body mass index (BMI) and overall, cancer, chronic obstructive pulmonary disease (COPD), asthma, and cardiovascular disease (CVD)-specific in-hospital mortality; postsurgical complications; and hospital length of stay (LOS).

DESIGN

Cross-sectional study.

SETTING

Representative sample of US hospitals included in the Health Cost and Utilization Project Nationwide Inpatient Sample database.

PARTICIPANTS

We obtained data for patients admitted with a primary diagnosis of cancer, COPD, asthma, and CVD.

MAIN OUTCOME

In-hospital mortality, postsurgical complications, and hospital LOS.

RESULTS

A total of 800,417 patients were included in this analysis. A higher proportion of Blacks (26.8%; 12.5%) and Whites (23.3%; 8.7%) had BMI of 40 to 49.9 and ≥50, respectively, compared with Hispanics (20.4%; 7.3%). Compared with normal BMI patients, the odds of in-hospital mortality increased 3.6-fold (odds ratio [OR] 3.62, 95% confidence interval [CI]: 3.37-3.89) for preobese patients, 6.5-fold (OR: 6.52, 95% CI: 5.79-7.34) for patients with BMI: 30 to 31.9, 7.5-fold (OR: 7.57, 95% CI: 6.67-8.59) for patients with BMI: 34 to 35.9, and 1.6- fold (OR: 1.77, 95% CI: 1.56-1.79) for patients with BMI ≥ 50. Compared with normal BMI patients, preobese and overweight patients had shorter hospital stays (β preobese: -1.58, 95% CI: -1.63, -1.52); however, no clear trends were observed for postsurgical complications.

CONCLUSIONS

The majority of hospitalized patients in this analysis had a BMI > 30, and higher BMI was associated with increased risk of mortality and longer hospital stay.

Prevalence of obesity in an intensive care unit patient population

BACKGROUND

The Australian health survey (2011-2012) reported that 63.4% of Australian adults were overweight or obese. Critical care medicine is expensive, with intensive care unit (ICU) services accounting for a substantial proportion of total hospital costs. These costs may be multiplied in the overweight cohort.

OBJECTIVES

The primary aim was to compare the body mass index (BMI) of a critically ill ICU patient cohort to Australian population norms in order to see if overweight people were over-represented. The secondary aim was to identify if any medical specialty was associated with overweight patients.

METHODS

A retrospective observational case note audit of 230 ICU patients between November 2012 and August 2013, with BMI as the primary outcome measure.

RESULTS

Approximately 75% of the cohort were overweight or obese (median BMI 28.7; IQR 25.0-32.7) representing a rate 12% higher than Australian normative data. Based on population, this equates to an estimated additional 5279 unanticipated overweight or obese ICU patients at our facility during 2013.

CONCLUSIONS

This study has shown that Australian ICU patients may have higher BMI than those of the general Australian population, and therefore there may be unanticipated costs associated with their care. No medical specialty was associated with higher BMI than another.

Perceived neighborhood environments and leisure-time walking among korean adults: an application of the theory of planned behavior

OBJECTIVE

To examine personal, social, and perceived environmental factors related to leisure-time walking behavior among Korean adults using the framework of the Theory of Planned Behavior (TPB).

BACKGROUND

Sedentary lifestyle and physical inactivity contribute to rising obesity rates and chronic diseases among Korean adults. Understanding correlates of walking is necessary to develop effective interventions to promote regular walking.

METHODS

A cross-sectional survey was conducted in 2008 among 424 Korean adults. Participants completed a questionnaire on perceived neighborhood environment, the TPB constructs, and leisure-time walking behavior.

RESULTS

Those who participated in leisure-time walking had more positive perceptions of aesthetics and expressed greater perceived behavioral control (PBC) and intention of walking than nonwalkers. Also, walking correlated with intention and PBC, and perceived crime safety. Intentions were moderately to strongly associated with attitude, PBC, and subjective norm. Integrating TPB constructs and the perceived environment variable (crime safety) resulted in a moderate fit of the data [χ(2)= 2.372, df = 5; p = 0.796; NFI = 0.99; RMSEA = 0.00] with approximately 45.6% variance of intention and 19.4% of the response variance of walking explained. The model showed that perceived safety from crime was not directly related to leisure-time walking, but indirectly predicted walking through the TPB model.

CONCLUSIONS

Perceived safety was identified as an important environmental variable among Korean adults, and the TPB offered a good prediction of walking behavior. Identifying individual, social, and neighborhood environmental correlates of walking can help develop policies to promote public health for a more active and healthier community.

Nursing Home Perspectives on the Admission of Morbidly Obese Patients From Hospitals to Nursing Homes

PURPOSE OF THE STUDY

Care challenges have been described for hospitalized morbidly obese (MO) patients. These challenges likely persist post discharge. As a result, nursing homes (NHs) may be reluctant to admit these patients, potentially leaving them "stranded in hospitals". This study identified issues NHs consider in admission decisions for MO patients transitioning from hospitals.

DESIGN AND METHOD

Approved surveys were mailed to nursing directors at federally-certified NHs in Arkansas (n = 234) and Pennsylvania (n = 710) to collect NH experience in the admission of patients weighing ≥ 325 pounds. Analyses included descriptive and inferential statistics to summarize and identify predictors of MO patient admission decisions.

RESULTS

In total, 360 surveys were returned (38.1% response rate). Although two-thirds of respondents reported patient size as an admission barrier, only 6% reported that MO patients were always refused admission. Adjusted analysis showed that NHs with adequate staff were significantly (p = .04) less likely to report obesity as an admission barrier whereas NHs reporting concerns about availability of bariatric equipment were significantly (p < .0001) more likely to report obesity as a barrier.

IMPLICATIONS

Lack of staff and bariatric equipment in NHs appears to negatively affect the transition of MO patients out of the hospital to NHs. Additional research, including examination of current regulations and reimbursement policies, should be undertaken to understand NH staffing and equipment acquisition decisions in light of the current obesity epidemic. Such research has implications for the optimal care of obese individuals during times of transition.

Obese patients and radiography literature: what do we know about a big issue?

Obesity is a global health issue with obese patients requiring specialised diagnosis, treatment and care through the health service. The practical and social difficulties associated with medical imaging of obese patients are an increasingly common problem and it is currently unknown how student and qualified radiographers perceive and respond to these challenges. By better understanding challenges presented in providing quality imaging and care of imaging obese patients, education for both qualified and student radiographers can be enhanced. Radiographers are heavily reliant on visual and tactile senses to locate the position of anatomical structures for diagnostic imaging and determine radiation exposure through a delicate consideration of dose, image quality and anatomical attenuation. However, obese patients require modifications to routine radiographic practice in terms of movement/assisted positioning, equipment capabilities to take increased weight or coverage. These patients may also be subject to compromised radiological diagnosis through poor visualisation of structures. In this paper, the professional and educational literature was narratively reviewed to assess gaps in the evidence base related to the skill and care knowledge for obese patients. Literature was sourced relating to discrete radiographic considerations such as the technical factors of imaging obese patients, exposure and the impact of obesity on imaging departments’ service provisions. The recent literature (post-2000 to coincide with the sharp increase in global obesity) on the perceptions of health professionals and student health practitioners has also been explored because there are no specific radiographer studies to report. By understanding the research in similar fields, we may identify what common attitudes qualified and student radiographer's hold and what challenges, technical and care related, can be prepared for.

Increased health services use by severely obese patients undergoing emergency surgery: a retrospective cohort study

BACKGROUND

The aim of this study was to assess perioperative outcomes in obese patients undergoing emergency surgery.

METHODS

We retrospectively reviewed the charts of all adult (> 17 yr) patients admitted to the acute care emergency surgery service at the University of Alberta Hospital between January 2009 and December 2011 who had a body mass index (BMI) of 35 or higher. Patients were divided into subgroups for analysis based on "severe" (BMI 35-39.9) and "morbid" obesity (BMI ≥ 40). Multivariate logistic regression was performed to identify predictors of in-hospital mortality after controlling for confounding factors.

RESULTS

Data on 111 patients (55% women, median BMI 39) were included in the final analysis. Intensive care unit (ICU) support was required for 40% of patients. Postoperative complications occurred in 42% of patients, and 31% required reoperation. Overall in-hospital mortality was 17%. Morbidly obese patients had increased rates of reoperation (40% v. 23%, p = 0.05) and increased lengths of stay compared with severely obese patients (14.5 v. 6.0 d, p = 0.09). Age (odds ratio [OR] 1.08 per increment) and preoperative ICU stay (OR 12) were significantly associated with in-hospital mortality after controlling for confounding, but BMI was not.

CONCLUSION

Obese patients requiring emergency surgery represent a complex patient population at high risk for perioperative morbidity and mortality. Greater resources are required for their care, including ICU support, repeat surgery and prolonged ICU stay. Future studies could help identify predictors of reoperation and strategies to optimize nutrition, rehabilitation and resource allocation.

Association between obesity and prescribed medication use in England

We investigate the association between obesity and use of prescribed medications in England. Data were taken from fourteen rounds of the Health Survey for England (1999-2012), which has measures of current prescribed medication use based on therapeutic classifications in the British National Formulary, and nurse-measured height and weight. We find that obesity has a statistically significant and positive association with use of a range of medicines for managing diseases associated with obesity. The mean probability of using any type of medication is 0.40 in those of normal weight, 0.44 in the overweight, 0.52 in obesity class I and 0.60 in obesity class II/III. Significant positive associations were found between obesity and the use of medication for diseases of the cardiovascular system, gastrointestinal system, respiratory system, and central nervous system, as well as for infections, endocrine system disorders, gynaecological/urinary disorders and musculoskeletal and joint disorders. Use of anti-obesity medication is low, even among those with class II/III obesity.

The effect of obesity on direct medical costs in total knee arthroplasty

BACKGROUND

Obesity prevalence continues to rise in the United States. We sought to examine the effect of obesity on length of hospital stay and direct medical costs in a large cohort of patients who underwent total knee arthroplasty.

METHODS

The study included 8129 patients who had undergone 6475 primary total knee arthroplasties and 1654 revision total knee arthroplasties at a large U.S. medical center from January 1, 2000, to September 30, 2008. Patients with bilateral procedures within ninety days following the index admission were excluded. Data on clinical and surgical characteristics and complications were obtained from the original medical records and the institutional joint registry. Patients were classified into eight groups based on their body mass index at the time of surgery. Direct medical costs were calculated in 2010 U.S. dollars by using standardized, inflation-adjusted costs for services and procedures billed during hospitalization and the ninety-day window. Study end points were hospital length of stay and direct medical costs. End points were compared across the eight body mass index categories in both unadjusted and multivariable risk-adjusted analyses. Linear regression models were used to determine the cost impact associated with increasing body mass index and obesity accounting for comorbidities and complications.

RESULTS

Body mass index data were available for 99.5% of patients and ranged from 15 to 73 kg/m2. Length of stay and the direct medical costs were lowest for patients with body mass index values in the normal to overweight range. Increasing body mass index was associated with significantly longer hospital stays and costs. Every 5-unit increase in body mass index beyond 30 kg/m2 was associated with approximately $250 to $300 higher hospitalization costs in primary total knee arthroplasty and $600 to $650 higher hospitalization costs in revision total knee arthroplasty. These estimates persisted after adjusting for comorbidities or complications.

CONCLUSIONS

Obesity is associated with longer hospital stays and higher costs in total knee arthroplasty. The effect of obesity on costs appears to be independent of obesity-related comorbid conditions and complications.

Obesity increases length of stay and direct medical costs in total hip arthroplasty

BACKGROUND

The number of obese patients undergoing THA is increasing. Previous studies have shown that obesity is associated with an increased likelihood of complications after THA, but there is little information regarding the impact of obesity on medical resource use and direct medical costs in THA.

QUESTIONS/PURPOSES

We sought to examine the relationship between obesity, length of stay, and direct medical costs in a large cohort of patients undergoing THAs.

METHODS

The study included 8973 patients who had undergone 6410 primary and 2563 revision THAs at a large US medical center between January 1, 2000, and September 31, 2008. Patients with bilateral procedures within 90 days after index admission and patients with acute trauma were excluded. Data regarding clinical, surgical characteristics, and complications were obtained from the original medical records and the institutional joint registry. Patients were classified into eight groups based on their BMI at the time of surgery. Direct medical costs were calculated by using standardized, inflation-adjusted costs for services and procedures billed during hospitalization and the 90-day window. Study end points were hospital length of stay, direct medical costs during hospitalization, and the 90-day window. End points were compared across the eight BMI categories in multivariable risk-adjusted linear regression models.

RESULTS

Mean length of stay and the direct medical costs were lowest for patients with a BMI of 25 to 35 kg/m(2). Increasing BMI was associated with longer hospital stays and costs. Every five-unit increase in BMI beyond 30 kg/m(2) was associated with approximately USD $500 higher hospital costs and USD $900 higher 90-day costs in primary THA (p = 0.0001), which corresponded to 5% higher costs. The cost increase associated with BMI was greater in the revision THA cohort where every five-unit increase in BMI beyond 30 kg/m(2) was associated with approximately USD $800 higher hospital costs and USD $1500 higher 90-day costs. These estimates remained unchanged after adjusting for comorbidities or complications.

CONCLUSIONS

Obesity is associated with longer hospital stays and higher costs in THA. The significant effect of obesity on costs persists even among patients without comorbidities but the increased costs associated with obesity may be balanced by the potential benefits of THA in the obese. Increasing prevalence of obesity likely contributes to the increasing financial burden of THA worldwide.

LEVEL OF EVIDENCE

Level IV, economic and decision analyses. See the Instructions for Authors for a complete description of levels of evidence.

Association of body mass index with increased cost of care and length of stay for emergency department patients with chest pain and dyspnea

BACKGROUND

High body mass index (BMI) increases the probability of indeterminate findings on diagnostic studies, length of stay, and cost of care for hospitalized patients. No study has examined the economic and operational impact of BMI in patients with chest complaints presenting to the emergency department (ED). The objective was to measure the association of BMI with the main outcomes of cost of care, length of stay (including time in the ED and time in the wards if admitted), and radiation exposure in patients presenting to the ED with chest pain and dyspnea.

METHODS AND RESULTS

This was a prospective, 4-center, outcomes study. Patients were adults with dyspnea and chest pain, nondiagnostic electrocardiograms, and no obvious diagnosis. Patients were followed for the main outcomes for 90 days. Outcomes that were stratified by BMI in 5 categories, underweight, normal weight, overweight, obese, and morbidly obese, were compared using the Kruskall-Wallis rank test, and the independent predictive value of BMI was tested with multivariate regressions. Compared with medical costs for normal weight patients, costs were 22% higher for overweight patients (P=0.077), 28% higher for obese patients (P=0.020), and 41% higher for morbidly obese patients (P=0.015). Morbidly obese patients without computerized tomographic scanning stayed in the hospital 34% longer than normal weight patients (P=0.073), and morbidly obese patients with computerized tomographic scanning stayed in the hospital 44% longer than normal weight patients (P=0.083). BMI was not a significant predictor of radiation exposure. Morbidly obese patients had the highest proportion (87%) of no significant cardiopulmonary diagnosis for 90 days after computerized tomographic pulmonary angiography.

CONCLUSIONS

BMI was associated with increases in cost of care and length of hospital stay for patients with chest pain and dyspnea. These results emphasize a need for specific protocols to manage morbidly obese patients presenting to the ED with chest pain and dyspnea. Clinical Trial Registration- http://www.clinicaltrials.gov. Unique identifier: NCT01059500.

Factors associated with longer length of hospital stay after primary elective ankle surgery for end-stage ankle arthritis

BACKGROUND

Longer length of stay in the hospital after elective surgery results in increased use of health-care resources and higher costs. Improved perioperative care permits many foot and ankle surgical procedures to be performed as day surgery. This study determined perioperative factors associated with a longer length of stay after elective total ankle replacement or ankle arthrodesis.

METHODS

Data were prospectively collected on patients who underwent open or arthroscopic ankle fusion or total ankle replacement for end-stage ankle arthritis at our institution from 2003 to 2010. Univariate and multivariable generalized linear regression models with gamma distribution and log link function were conducted with use of the length of the hospital stay as the dependent variable and preselected risk factors of age, sex, physical and mental functional scores, comorbid factors, American Society of Anesthesiologists grade, body mass index, type of surgery, duration of surgery, and surgery day of the week as the independent variables.

RESULTS

This study included 343 patients with a median length of stay of seventy-five hours (interquartile range, fifty-two to ninety-seven hours). With use of regression analyses, the variables of age, female sex, higher American Society of Anesthesiologists grade, multiple medical comorbidities, rheumatoid arthritis, lower Short Form-36 Physical Component Summary and General Health domain scores, and open surgery were significantly associated with increased length of stay. Conversely, the variables of obesity, Short Form-36 Mental Component Summary score, surgery day of the week, and surgical duration were not associated with length of stay. Two predictive models of the length of stay were developed: one included only patient-related factors, and the other included patient and surgery-related factors.

CONCLUSIONS

The patients who are identified with a higher risk of a longer length of stay may warrant better education and more focused perioperative care when designing care pathways and allocating health-care resources.

Health care and lost productivity costs of overweight and obesity in New Zealand

OBJECTIVE

To estimate the costs of health care and lost productivity attributable to overweight and obesity in New Zealand (NZ) in 2006.

METHODS

A prevalence-based approach to costing was used in which costs were calculated for all cases of disease in the year 2006. Population attributable fractions (PAFs) were calculated based on the relative risks obtained from large cohort studies and the prevalence of overweight and obesity. For each disease, the PAF was multiplied by the total health care cost. The costs of lost productivity associated with premature mortality were estimated using both the Human Capital approach (HCA) and Friction Cost approach (FCA).

RESULTS

Health care costs attributable to overweight and obesity were estimated to be NZ$686m or 4.5% of New Zealand's total health care expenditure in 2006. The costs of lost productivity using the FCA were estimated to be NZ$98m and NZ$225m using the HCA. The combined costs of health care and lost productivity using the FCA were $784m and $911m using the HCA.

CONCLUSION

The cost burden of overweight and obesity in NZ is considerable.

IMPLICATIONS

Policies and interventions are urgently needed to reduce the prevalence of obesity thereby decreasing these substantial costs.

Health-related behaviors in women with lifestyle-related diseases

Lifestyle related diseases associated with physical inactivity and poor diet quality, represent a major health burden. This study assessed negative and positive health habits and health care utilization in healthy women (n = 50) and women with lifestyle related diseases such as polycystic ovary syndrome (PCOS) (n = 50), gestational diabetes mellitus (GDM) (n = 44) and type 2 diabetes (DM2) (n = 43). A significant difference existed across groups for negative health habits (P = .012) with a trend for positive health habits (P = .06) elevated in women with PCOS. Women with DM2 had the highest amount of health care utilization including doctors office visits (P < .001), overnight hospital treatments (P < .001) and emergency room treatments (P = .01). Health practitioners would benefit from both encouraging positive health habits and addressing negative health habits. Furthermore, self-management and emphasizing the pivotal role patients' have in managing their illness is important for optimizing health outcomes. Elevated health care utilization rates were observed in women with DM2 but there were no differences in positive health habits across sub-groups. Encouraging lifestyle modification in women with precursor diseases such as GDM and PCOS is vital in order to prevent progression to DM2.

Obesity in pediatric specialty clinics: an underestimated comorbidity

OBJECTIVES

(a) To examine the prevalence of obesity across 31 subspecialties in a tertiary care children's hospital and (b) to examine the percentage of obesity-specified diagnosis codes used for obese patient visits.

METHODS

We analyzed 48 479 youth aged 2 to 18 years in 31 outpatient subspecialty clinics at Seattle Children's Hospital between 2005 and 2007. Body mass index (BMI) percentiles were determined by age- and gender-adjusted BMI calculated from height/weight obtained at clinic visits. For obese patients, the percentage of diagnoses coded as obesity-specific (278.11, 278.01, 272.02, 783.1) were determined by evaluation of standard diagnostic codes.

RESULTS

Twenty-two of the 31 clinics had patient obesity rates greater than 15%. Analysis of International Classification of Diseases, 9th Revision, codes for obese patient visits as defined by BMI revealed only 2 clinics used obesity-specific codes for >5% of all diagnoses.

CONCLUSIONS

Given the prevalence of obesity across all subspecialties, more recognition and resources are needed to screen, diagnosis, and provide coordinated services for healthy weight management.