A population-based evaluation of readmissions after first hospitalization for acute pancreatitis

Racial and Ethnic Minorities With Acute Pancreatitis Live in Neighborhoods With Higher Social Vulnerability Scores

OBJECTIVES

The primary objective was to determine differences in Social Vulnerability Index (SVI) scores among minorities (African-Americans and Hispanics) with acute pancreatitis (AP) compared with non-Hispanic whites (NHWs) with AP. The secondary objectives were to determine differences in diet, sulfidogenic bacteria gene copy numbers (gcn) and hydrogen sulfide (H2S) levels between the 2 groups.

MATERIALS AND METHODS

Patients with AP were enrolled during hospitalization (n = 54). Patient residential addresses were geocoded, and the Centers for Disease Control and Prevention's SVI scores were appended. Dietary intake and serum H2S levels were determined. Microbial DNAs were isolated from stool, and gcn of sulfidogenic bacteria were determined.

RESULTS

Minorities had higher SVI scores compared with NHWs ( P = 0.006). They also had lower consumption of beneficial nutrients such as omega-3 fatty acids [stearidonic ( P = 0.019), and eicosapentaenoic acid ( P = 0.042)], vitamin D ( P = 0.025), and protein from seafood ( P = 0.031). Lastly, minorities had higher pan-dissimilatory sulfite reductase A ( pan-dsrA ) gcn ( P = 0.033) but no significant differences in H2S levels ( P = 0.226).

CONCLUSION

Minorities with AP have higher SVI compared with NHWs with AP. Higher SVI scores, lower consumption of beneficial nutrients, and increased gcn of pan-dsrA in minorities with AP suggest that neighborhood vulnerability could be contributing to AP inequities.

Early systemic anticoagulation reduces hospital readmission in acute necrotizing pancreatitis patients: A retrospective cohort study

BACKGROUND

Early systemic anticoagulation (SAC) is a common practice in acute necrotizing pancreatitis (ANP), and its impact on in-hospital clinical outcomes had been assessed. However, whether it affects long-term outcomes is unknown. This study aimed to evaluate the effect of SAC on 90-day readmission and other long-term outcomes in ANP patients.

METHODS

During January 2013 and December 2018, ANP patients admitted within 7 days from the onset of abdominal pain were screened. The primary outcome was 90-day readmission after discharge. Cox proportional-hazards regression model and mediation analysis were used to define the relationship between early SAC and 90-day readmission.

RESULTS

A total of 241 ANP patients were enrolled, of whom 143 received early SAC during their hospitalization and 98 did not. Patients who received early SAC experienced a lower incidence of splanchnic venous thrombosis (SVT) [risk ratio (RR) = 0.40, 95% CI: 0.26-0.60, P < 0.01] and lower 90-day readmission with an RR of 0.61 (95% CI: 0.41-0.91, P = 0.02) than those who did not. For the quality of life, patients who received early SAC had a significantly higher score in the subscale of vitality (P = 0.03) while the other subscales were all comparable between the two groups. Multivariable Cox regression model showed that early SAC was an independent protective factor for 90-day readmission after adjusting for potential confounders with a hazard ratio of 0.57 (95% CI: 0.34-0.96, P = 0.04). Mediation analysis showed that SVT mediated 37.0% of the early SAC-90-day readmission causality.

CONCLUSIONS

The application of early SAC may reduce the risk of 90-day readmission in the survivors of ANP patients, and reduced SVT incidence might be the primary contributor.

Type 1 Diabetes in Acute Pancreatitis Consortium: From Concept to Reality

ABSTRACT

Acute pancreatitis (AP), resulting from inflammation of the pancreas, accounts for more than 300,000 US hospital discharges per year. Although glucose intolerance has been known as a complication of severe AP, this effect was thought to be transient. Recently, cohort studies and meta-analysis of 24 published studies of 1100 patients who survived one or more episodes of AP revealed that 30% to 40% of patients developed diabetes or impaired glucose tolerance within 3 to 4 years of even a single episode of AP. The National Institute of Diabetes and Digestive and Kidney Diseases funded the Type 1 Diabetes in Acute Pancreatitis Consortium (T1DAPC) to undertake a prospective observational study of the occurrence of diabetes during an AP episode or subsequently, with emphasis on type 1 diabetes. Key factors for funding T1DAPC are the increasing incidence and prevalence of AP, its association with the development of type 1 diabetes and other forms of diabetes after AP, its complications, and associated health care cost. The T1DAPC structure, governance, and research objectives are described in this article. The DREAM (Diabetes RElated to Acute pancreatitis and its Mechanisms) studies to be undertaken by the T1DAPC are described in other articles in this journal's issue.

Rationale and Design for the Diabetes RElated to Acute Pancreatitis and Its Mechanisms Study: A Prospective Cohort Study From the Type 1 Diabetes in Acute Pancreatitis Consortium

ABSTRACT

Acute pancreatitis (AP) is a disease characterized by an acute inflammatory phase followed by a convalescent phase. Diabetes mellitus (DM) was historically felt to be a transient phenomenon related to acute inflammation; however, it is increasingly recognized as an important late and chronic complication. There are several challenges that have prevented precisely determining the incidence rate of DM after AP and understanding the underlying mechanisms. The DREAM (Diabetes RElated to Acute Pancreatitis and its Mechanisms) Study is a prospective cohort study designed to address these and other knowledge gaps to provide the evidence needed to screen for, prevent, and treat DM after AP. In the following article, we summarize literature regarding the epidemiology of DM after AP and provide the rationale and an overview of the DREAM study.

Thirty-Day Readmission Among Patients with Alcoholic Acute Pancreatitis

BACKGROUND/OBJECTIVES

Alcoholic acute pancreatitis (AAP) comprises the second most common cause of acute pancreatitis in the USA, and there is lack of data regarding 30-day specific readmission causes and predictors. We aim to identify 30-day readmission rate, causes, and predictors of readmission.

METHODS

Retrospective analysis of the 2016 National Readmission Database of adult patients readmitted within 30 days after an index admission for AAP.

RESULTS

Totally, 76,609 AAP patients were discharged from the hospital in 2016. The 30-day readmission rate was 12%. The main cause of readmission was another episode of AAP. Readmission was not associated with higher mortality (1.3% vs. 1.2%; P = 0.21) or prolonged length of stay (5.2 vs. 5.0 days; P = 0.06). The total health care economic burden was $354 million in charges and $90 million in costs. Independent predictors of readmission were having Medicaid insurance, a Charlson comorbidity index score ≥ 3, use of total parenteral nutrition, opioid abuse disorder, prior pancreatic cyst, chronic alcoholic pancreatitis, and other chronic pancreatitis. Obesity was associated with lower odds of readmission.

CONCLUSION

Readmission rate for AAP is high and its primary cause are recurrent episodes of AAP. Alcohol and substance abuse pose a high burden on our health care system. Public health strategies should be targeted to provide alcohol abuse disorder rehabilitation and cessation resources to alleviate the burden on readmission, the health care system and to improve patient outcomes.

Immune Dysfunction is Associated with Readmission in Survivors of Sepsis Following Infected Pancreatic Necrosis

Objective

Immunosuppression is common in patients with infected pancreatic necrosis (IPN) and associated with morbidity and mortality. This study aimed to investigate the impact of immune status on mortality and readmission after hospital discharge in patients with IPN-related sepsis.

Methods

In this prospective observational study, eligible adult patients with IPN-related sepsis requiring ICU admission were included. Monocytic human leukocyte antigen DR (mHLA-DR), expression of regulatory T cells (Treg), and neutrophil CD88 (nCD88) were measured on the diagnosis of sepsis, ICU discharge, hospital discharge, and 15, 30, 60 days after hospital discharge. Logistic regression model was used to assess potential risk factors for readmission 60-days within the index discharge.

Results

A total of 53 patients were included, 13 died during hospitalization and one withdrew the consent soon after discharge. Among the survivors, a tendency of immune recovery was observed during the consecutive follow-ups, evidenced by the increased expression of mHLA-DR. Sixteen patients (41.03%) were readmitted within 60 days after the index discharge. In the multivariable regression model, APACHE II score when sepsis was diagnosed >9 and mHLA-DR at discharged <14,591 AB/C were found to be independent risk factors affecting readmission.

Conclusion

Immunosuppression is common in patients with IPN-related sepsis and can persist until two months after discharge. The compromised mHLA-DR level at discharge was associated with readmission within two months after discharge.

A Case-CrossovEr study deSign to inform tailored interventions to prevent disease progression in Acute Pancreatitis (ACCESS-AP) - study design and population

BACKGROUND/OBJECTIVES

Alcohol is the most common etiology of recurrent acute pancreatitis and chronic pancreatitis. The extent and timing of drinking that increases the transient risk of acute pancreatitis is yet unknown.

METHODS

We designed a case-crossover study to determine the effective hazard period of drinking in relation to episodes of pancreatitis. We aim to evaluate the dose-response relationship between excess drinking and pancreatitis comparing the extent of drinking during case and control periods from the same individual. We aim to recruit 160 patients hospitalized with acute pancreatitis, whose AUDIT-C score reaches 3 or higher. Interviews of each enrolled patient to define their 15-day history of alcohol consumption employing the timeline follow-back method. Long-term drinking and smoking will be investigated as modifiers of the impact of short-term excess drinking. Patients are followed-up for evaluation of usual alcohol consumption during asymptomatic periods following the index hospitalization. Blood and urine specimens are collected while the patients are hospitalized and during a standard-of-care follow-up visit.

RESULTS

We have recruited 31 patients to date, with a median age of 33 years. Females and non-White participants make up 26% and 35% of the enrolled population, respectively. Forty-eight % of patients have had a prior history of acute pancreatitis.

CONCLUSIONS

Our study will shed light on the impact of short-term changes in drinking on triggering acute pancreatitis. It will provide data on other covarying factors of drinking and behaviors changes after acute pancreatitis.

The national institutes of health's approach to address research gaps in pancreatitis, diabetes and early detection of pancreatic cancer

PURPOSE OF REVIEW

Diseases of the pancreas are a broad spectrum of conditions resulting from metabolic, inflammatory, and neoplastic processes (pancreatitis, pancreatogenic diabetes, and pancreatic cancers). Pancreatic diseases cause significant morbidity, mortality, and cost.

RECENT FINDINGS

Research progress in diseases of the exocrine pancreas (chronic pancreatitis [CP], pancreatogenic diabetes mellitus, and pancreatic cancer) has been hampered by the disorders' heterogeneity, the limitations of previous small cross-sectional studies, the inability to safely obtain pancreatic tissue for study, and the lack of structured epidemiology tools, genetic testing, and biomarker development.

SUMMARY

Given the increasing incidence and prevalence of CP and its complications, high mortality rate, and associated healthcare cost, the National Institute of Diabetes and Digestive and Kidney Diseases and the National Cancer Institute funded the Consortium for the study of Chronic Pancreatitis, Diabetes and Pancreatic Cancer (CPDPC) to identify research gaps and foster multidisciplinary collaborations to better diagnose, characterize and manage CP and its sequelae and to understand the diabetes/pancreatic cancer association.The studies undertaken by the CPDPC are described in other articles in this journal's issue.

Diabetes following acute pancreatitis

Diabetes represents a group of diseases involving persistent hyperglycaemia. Exocrine disorders of the pancreas are increasingly recognised to cause or precede the onset of diabetes, which in this context is referred to as pancreatogenic or type 3c diabetes. Diabetes, as a sequela of acute pancreatitis, is observed across the spectrum of severity in acute pancreatitis and can be associated with other clinical complications. The pathophysiology of acute pancreatitis-related diabetes is poorly understood, and observations suggest that it is probably multifactorial. In this Review, we discuss the epidemiology, pathophysiology, and management considerations of diabetes following acute pancreatitis, and highlight knowledge gaps in this topic.

Identification of a Risk Profile for New-Onset Diabetes After Acute Pancreatitis

OBJECTIVES

There is a paucity of studies evaluating predictors of new-onset diabetes mellitus (DM) after acute pancreatitis (AP-related DM). We used a population-based database to evaluate predictors of AP-related DM.

METHODS

The Nationwide Readmissions Database (2010-2014) was used to identify all nondiabetic adults with an index primary diagnosis of AP. Multiple exclusions were applied to identify cohorts with and without AP-related DM. A case-control study was conducted to identify risk factors for developing AP-related DM within the calendar year.

RESULTS

We identified 2510 subjects with AP-related DM and 40,308 controls with AP who did not develop DM. Multivariable analysis revealed that increasing age (50-64 years; adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.14-1.60), male sex (aOR, 1.2; 95% CI, 1.03-1.40), lowest income quartile (aOR, 1.48; 95% CI, 1.18-1.84), Elixhauser comorbidity index of 3 or higher (aOR, 1.47; 95% CI, 1.23-1.75), components of metabolic syndrome (aOR, 2.12; 95% CI, 1.21-3.70), severe AP (aOR, 1.60; 95% CI, 1.34-1.90), and recurrent AP (aOR, 1.46; 95% CI, 1.24-1.72) were independently associated with increased risk of AP-related DM.

CONCLUSIONS

These population-level variables predictive of developing AP-related DM can potentially identify patients who may benefit from closer follow-up, intensive education, and implementation of preventative strategies.

The Short- and Long-Term Burden of Acute Pancreatitis in the United States: A Retrospective Cohort Study

OBJECTIVES

This retrospective cohort study assessed short- and long-term economic, clinical burden, and productivity impacts of acute pancreatitis (AP) in the United States.

METHODS

United States claims data from patients hospitalized for AP (January 1, 2011-September-30, 2016) were sourced from MarketScan databases. Patients were categorized by index AP severity: severe intensive care unit (ICU), severe non-ICU, and other hospitalized patients.

RESULTS

During index, 41,946 patients were hospitalized or visited an emergency department for AP. For inpatients, median (interquartile range) AP-related total cost was $13,187 ($12,822) and increased with AP severity (P < 0.0001). During the postindex year, median AP-related costs were higher (P < 0.0001) for severe ICU versus severe non-ICU and other hospitalized patients. Hours lost and costs due to absence and short-term disability were similar between categories. Long-term disability costs were higher (P = 0.005) for severe ICU versus other hospitalized patients. Factors associated with higher total all-cause costs in the year after discharge included AP severity, length of hospitalization, readmission, AP reoccurrence, progression to chronic pancreatitis, or new-onset diabetes (P < 0.0001).

CONCLUSIONS

An AP event exerts substantial burden during hospitalization and involves long-term clinical and economic consequences, including loss of productivity, which increase with index AP event severity.

Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis

The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55–4.65 and 2.22–4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04–2.84 and 0.96–2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08–2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.

Class III obesity rather than metabolic syndrome impacts clinical outcomes of acute pancreatitis: A propensity score weighted analysis

OBJECTIVES

The incidence rates of acute pancreatitis (AP) and the prevalence of class III obesity, and metabolic syndrome (MetS) are increasing in the US. Since class III obesity was associated with adverse clinical outcomes of AP, we sought to understand if the presence of metabolic comorbidities collectively recognized, as MetS were associated with worse clinical outcomes and increased health-care utilization.

METHODS

The Nationwide Readmissions Database (NRD) (2010-2014) was reviewed to identify all adult subjects with a principal discharge diagnosis of AP. Inpatient mortality, severe AP (SAP), and 30-day readmissions were the primary outcomes analyzed. Propensity score weighted analyses were used to compare AP subjects with and without MetS and were further stratified by class III obesity status.

RESULTS

MetS was associated with 12.91% (139,165/1,078,183) of all admissions with AP. Propensity score weighted analyses showed that MetS was associated with an increased proportion of SAP (OR 1.21, 95% CI 1.17, 1.25), but decreased mortality (OR 0.62, 95% CI 0.54, 0.70) and 30-day readmissions (OR 0.86, 95% CI 0.83, 0.89). Propensity score weighted analyses also revealed that class III obesity was independently associated with increased mortality in AP subjects with (OR 1.92, 95% CI 1.41, 2.61) and without MetS (OR 1.55, 95% CI 1.26, 1.92), and increased SAP in subjects with and without MetS.

CONCLUSIONS

Class III obesity appears to be the primary factor associated with adverse clinical outcomes in subjects with MetS admitted with AP. This has significant implications for patient management and future research targeting AP.

Different Hospital Readmissions and Outcomes of Acute Pancreatitis

OBJECTIVES

Although acute pancreatitis (AP) is associated with recurrent hospitalizations, the impact of different hospital readmissions (DHR) versus same hospital readmissions (SHR) on outcomes is unknown. We study the burden of DHR among readmissions after survival from AP hospitalizations.

METHODS

Among adult AP patients (Nationwide Readmissions Database), we calculated the prevalence, trends, and predictors of DHR, and its impact on mortality, hospital stay, and charges during 30- and 90-day readmissions.

RESULTS

From 2010 to 2014, 15% and 26% of AP hospitalizations (422,950) were readmitted in 30 and 90 days, respectively. The DHR rates were similar (26.3%, 30 days; 26.4%, 90 days) and unchanged from 2010 to 2014 (Ptrends > 0.10). The predictors of DHR were similar during both readmissions and included younger age category (18-45 years), hospital characteristics (nonteaching, small bed size, nonmicropolitan/metropolitan areas), substance abuse, comorbidities, and nonreception of cholecystectomy and pancreatectomy during index hospitalizations.During readmissions (30 and 90 days), DHR was associated with adjusted odds ratio (95% confidence interval), higher mortality (1.40 [1.19-1.64] and 1.50 [1.32-1.71]), longer hospital stay (1.3 days [1.1-1.7 days] and 1.1 days [0.9-1.3 days]), and higher charges (US $16,779 [US $13,898-US $20,254] and US $14,299 [US $12,299-US $16,623]).

CONCLUSIONS

Targeted measures are needed toward patients at risk for DHR to curb the poor outcomes.

High Rates of Readmission in Necrotizing Pancreatitis: Natural History or Opportunity for Improvement?

BACKGROUND

Necrotizing pancreatitis (NP) is a complex and heterogeneous disease with a protracted disease course. Hospital readmission is extremely common; however, few data exist regarding the cause of readmission in NP.

METHODS

A retrospective review of NP patients treated between 2005 and 2017 identified patients readmitted both locally and to our hospital. All patients with unplanned hospital readmissions were evaluated to determine the cause for readmission. Clinical and demographic factors of all patients were recorded. As appropriate, two independent group t tests and Pearson's correlation or Fisher's exact tests were performed to analyze the relationship between index admission clinical factors and readmission. p values of < 0.05 were accepted as statistically significant.

RESULTS

Six hundred one NP patients were reviewed. Median age was 52 years (13-96). Median index admission length of stay was 19 days (2-176). The most common etiology was biliary (49.9%) followed by alcohol (20.0%). Unplanned readmission occurred in 432 patients (72%) accounting for a total of 971 unique readmissions (mean readmissions/patient, 2.3). The most common readmission indications were symptomatic necrosis requiring supportive care and/or intervention (31.2%), infected necrosis requiring antibiotics and/or intervention (26.6%), failure to thrive (9.7%), and non-necrosis infection (6.6%). Patients requiring readmission had increased incidence of index admission renal failure (21.3% vs. 14.2%, p = 0.05) and cardiovascular failure (12.5% vs. 4.7%, p = 0.01).

DISCUSSION

Readmission in NP is extremely common. Significant portions of readmissions are a result of the disease natural history; however, a percentage of readmissions appear to be preventable. Patients with organ failure are at increased risk for unplanned readmission and will benefit from close follow-up.

Acute Biliary Pancreatitis is Associated With Adverse Outcomes in the Elderly: A Propensity Score-Matched Analysis

GOALS AND BACKGROUND

In the elderly (age, 65 y or older), acute pancreatitis is most frequently because of gallstones; however, there is a paucity of national estimates evaluating outcomes of acute biliary pancreatitis (ABP). Hence, we utilized a representative population database to evaluate the outcomes of ABP among the elderly.

STUDY

The National Readmission Database provides longitudinal follow-up of inpatients for 1 calendar-year. All adult inpatients (18 y or older) with an index primary admission for ABP between 2011 and 2014 were evaluated for clinical outcomes of mortality, severe acute pancreatitis (SAP), and 30-day readmission. Outcomes between age groups (≥65 vs. <65 y) were compared using multivariate and one-to-one propensity score-matched analyses.

RESULTS

Among 184,763 ABP admissions, 41% were elderly. Index mortality and SAP rates in the elderly were 1.96% and 21.5%, respectively. Elderly patients underwent more ERCPs (27.5% vs. 23.6%; P<0.001) and less frequent cholecystectomies (44.4% vs. 58.7%; P<0.001). Elderly patients had increased odds of mortality and SAP along with an age-dependent increase in the odds of adverse outcomes; patients aged 85 years or older demonstrated the highest odds of SAP [odds ratio (OR), 1.3; 95% confidence interval (CI): 1.2, 1.4] and mortality (OR, 2.2; 95% CI: 1.7, 2.9) within in the elderly cohort. Propensity score-matched analysis substantiated that mortality (OR, 2.8; 95% CI: 2.2, 3.5) and SAP (OR, 1.2; 95% CI: 1.1, 1.3) were increased in the elderly.

CONCLUSIONS

Current national survey reveals adverse clinical outcomes among elderly patients hospitalized with ABP. Consequently, there is a need for effective management strategies for this demographic as the aging population is increasing nationally.

Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis

BACKGROUND

The timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare same-admission laparoscopic cholecystectomy (SA-LC) and delayed laparoscopic cholecystectomy (DLC) after mild acute biliary pancreatitis (MABP).

METHODS

We systematically searched several databases (PubMed, EMBASE, Web of Science, and the Cochrane Library) for relevant trials published from 1 January 1992 to 1 June 2018. Human prospective or retrospective studies that compared SA-LC and DLC after MABP were included. The measured outcomes were the rate of conversion to open cholecystectomy (COC), rate of postoperative complications, rate of biliary-related complications, operative time (OT), and length of stay (LOS). The meta-analysis was performed using Review Manager 5.3 software (The Cochrane Collaboration, Oxford, United Kingdom).

RESULTS

This meta-analysis involved 1833 patients from 4 randomized controlled trials and 7 retrospective studies. No significant differences were found in the rate of COC (risk ratio [RR] = 1.24; 95% confidence interval [CI], 0.78-1.97; p = 0.36), rate of postoperative complications (RR = 1.06; 95% CI, 0.67-1.69; p = 0.80), rate of biliary-related complications (RR = 1.28; 95% CI, 0.42-3.86; p = 0.66), or OT (RR = 1.57; 95% CI, - 1.58-4.72; p = 0.33) between the SA-LC and DLC groups. The LOS was significantly longer in the DLC group (RR = - 2.08; 95% CI, - 3.17 to - 0.99; p = 0.0002). Unexpectedly, the subgroup analysis showed no significant difference in LOS according to the Atlanta classification (RR = - 0.40; 95% CI, - 0.80-0.01; p = 0.05). The gallstone-related complications during the waiting time in the DLC group included gall colic, recurrent pancreatitis, acute cholecystitis, jaundice, and acute cholangitis (total, 25.39%).

CONCLUSION

This study confirms the safety of SA-LC, which could shorten the LOS. However, the study findings have a number of important implications for future practice.

Cholecystectomy During Index Admission for Acute Biliary Pancreatitis Lowers 30-Day Readmission Rates

OBJECTIVES

Few studies have evaluated national readmission rates after acute pancreatitis (AP) in the United States. We sought to evaluate modifiable factors impacting 30-day readmissions after AP hospitalizations.

METHODS

We used the Nationwide Readmission Database (2013) involving all adults with a primary discharge diagnosis of AP. Multivariable logistic regression models assessed independent predictors for specific outcomes.

RESULTS

Among 180,480 patients with AP index admissions, 41,094 (23%) had biliary AP, of which 10.5% were readmitted within 30 days. The 30-day readmission rate for patients who underwent same-admission cholecystectomy (CCY) was 6.5%, compared with 15.1% in those who did not (P < 0.001). Failure of index admission CCY increased the risk of readmissions (odds ratio [OR], 2.27; 95% confidence interval [CI], 2.04-2.56). Same-admission CCY occurred in 55% (n = 19,274) of patients without severe AP. Severe AP (OR, 0.73; 95% CI, 0.65-0.81), sepsis (OR, 0.63; 95% CI, 0.52-0.75), 3 or more comorbidities (OR, 0.74; 95% CI, 0.68-0.79), and admissions to small (OR, 0.76; 95% CI, 0.64-0.91) or rural (OR, 0.78; 95% CI, 0.65-0.95) hospitals were less likely to undergo same-admission CCY.

CONCLUSIONS

Same-admission CCY should be considered in patients with biliary AP when feasible. This national appraisal recognizes modifiable risk factors to reduce readmission in biliary AP and reinforces adherence to major society guidelines.

Known genetic susceptibility factors for chronic pancreatitis in patients of European ancestry are rare in patients of African ancestry

BACKGROUND

Multiple pathogenic genetic variants are associated with pancreatitis in patients of European (EA) and Asian ancestries, but studies on patients of African ancestry (AA) are lacking. We evaluated the prevalence of known genetic variations in African-American subjects in the US.

METHODS

We studied prospectively enrolled controls (n = 238) and patients with chronic (CP) (n = 232) or recurrent acute pancreatitis (RAP) (n = 45) in the NAPS2 studies from 2000-2014 of self-identified AA. Demographic and phenotypic information was obtained from structured questionnaires. Ancestry and admixture were evaluated by principal component analysis (PCA). Genotyping was performed for pathogenic genetic variants in PRSS1, SPINK1, CFTR and CTRC. Prevalence of disease-associated variants in NAPS2 subjects of AA and EA was compared.

RESULTS

When compared with CP subjects of EA (n = 862), prevalence of established pathogenic genetic variants was infrequent in AA patients with CP, overall (29 vs. 8.19%, OR 4.60, 95% CI 2.74-7.74, p < 0.001), and after stratification by alcohol etiology (p < 0.001). On PCA, AA cases were more heterogeneous but distinct from EA subjects; no difference was observed between AA subjects with and without CP-associated variants. Of 19 A A patients with CP who had pathogenic genetic variants, 2 had variants in PRSS1 (R122H, R122C), 4 in SPINK1 (all N34S heterozygotes), 12 in CFTR (2 CFTR^sev, 9 CFTR^BD, 1 compound heterozygote with CFTR^sev and CFTR^BD), and 1 in CTRC (R254W).

CONCLUSION

Pathogenic genetic variants reported in EA patients are significantly less common in AA patients. Further studies are needed to determine the complex risk factors for AA subjects with pancreatitis.

Incidence and Predictors of Readmissions in Acute Pancreatitis: A Nationwide Analysis

OBJECTIVES

Acute pancreatitis (AP) is a common cause for hospitalization, and readmission is common, with variable associated risk factors for readmission. Here, we assessed the incidence and risk factors for readmission in AP in a large national database.

METHODS

We analyzed data from the National Readmission Database during the year 2013. Index admissions with a primary discharge diagnosis of AP using the International Classification of Diseases, Ninth Revision, Clinical Modification were identified from January to November to identify 30-day readmission rates. Demographic, hospital, and clinical diagnoses were included in multivariate regression analysis to identify readmission risk factors.

RESULTS

We identified 243,816 index AP discharges with 39,623 (16.2%) readmitted within 30 days. The most common reason for readmission was recurrent AP (41.5%). Increased odds of all-cause readmission were associated with younger age, nonhome discharge, increasing Charlson Comorbidity Index, and increased length of stay. Cholecystectomy during index admission was associated with reduced all-cause and recurrent AP readmissions (odds ratios of 0.5, and 0.35, respectively).

CONCLUSIONS

Readmission for AP is common, most often due to recurrent AP. Multiple factors, including cholecystectomy, during index admission, are associated with significantly reduced odds of all-cause and recurrent AP readmissions.

Predictors for early readmission in acute pancreatitis (AP) in the United States (US) - A nationwide population based study

BACKGROUND & AIMS

Population based data on the burden and patterns of acute pancreatitis (AP) early readmissions (≤30-days) are limited.

METHODS

2013 Nationwide Readmission Database (NRD) was queried. AP etiology was determined using associated diagnoses codes. Proportion, reasons for readmission, and associated costs were evaluated. Multivariate logistic regression analysis was performed to identify independent predictors for 30-day readmission.

RESULTS

After exclusions, we identified 178,541 patients with primary diagnosis of AP (mean age 53 ± 17 years, 51% male). 13.7% were readmitted ≤30 days [7.1% in acute biliary pancreatitis (ABP) patients with index cholecystectomy (CCY), 16.3% in ABP patients without CCY, and 14.3% in non-biliary AP patients (p < 0.0001)]. Reasons for readmission included AP, chronic pancreatitis, Pseudocyst/walled off necrosis, biliary tract disease, smoldering symptoms and others. On multivariate analysis male gender, comorbidity status (≥3), non-biliary etiology, organ failure, Pseudocyst/walled off necrosis complications, and patients discharged to extended care facilities were associated with increased risk of readmission. ABP patients with index CCY had a significantly lower risk of early unplanned readmission (odds ratio 0.45, p < 0.0001) but ABP patients with index ERCP did not (p = 0.96).

CONCLUSIONS

About 1 in 7 AP patients had a 30-day readmission after index hospitalization and about half of these were related to AP. Our data confirms the higher risk of readmission in alcohol and idiopathic AP and a lower risk in ABP. Risk of early unplanned readmission is significantly lower in ABP patients who underwent CCY and not ERCP during index hospitalization. Cholecystectomy should be performed in all ABP patients as per recommended guidelines.

Clinical Profile and Natural Course in a Large Cohort of Patients With Hypertriglyceridemia and Pancreatitis

GOALS

To report the clinical profile and natural course in a large series of patients with hypertriglyceridemia (HTG) and acute pancreatitis (AP).

BACKGROUND

The natural history of HTG-related pancreatitis is poorly defined.

STUDY

Medical records of 121 patients with serum triglycerides (TG) levels of ≥500 mg/dL suffering 225 attacks of AP between January 2001 to August 2013 treated at the University of Pittsburgh Medical Center were retrospectively studied. Structured data were collected on initial presentation and long-term outcomes (mean follow-up 64.7±42.8 mo). AP severity was classified using Revised Atlanta Classification.

RESULTS

Most patients were young-middle aged (mean 44±12.7 y), male (70%), white (78%), and had sentinel AP (63%). Peak serum TG recorded was ≥1000 mg/dL in 48%. At least 1 secondary risk factor (diabetes, high-risk drinking, obesity, offending medications) was present in the majority (78%). Sentinel AP attack varied in severity between mild (41%), moderate (26%), and severe (33%). Recurrent AP attacks occurred in 32%, often in patients with poorly controlled diabetes, alcoholism, and TG levels. A cumulative increase in prevalence of pancreatic and/or peripancreatic necrosis was observed, with 45% patients having it at some time during observation. Local complications were higher in patients with serum TG ≥1000 mg/dL. Chronic pancreatitis was noted in 16.5% patients (new-onset in 9%).

CONCLUSIONS

Patients with HTG-related pancreatitis have a high prevalence of secondary risk factors. Frequent recurrences in them are usually due to poor control of secondary factors or TG. Serum TG ≥1000 mg/dL increases the risk of local complications. A subset can have or develop chronic pancreatitis.

Racial Differences in the Clinical Profile, Causes, and Outcome of Chronic Pancreatitis

OBJECTIVES

Racial differences in susceptibility and progression of pancreatitis have been reported in epidemiologic studies using administrative or retrospective data. There has been little study, however, on the clinical profile, causes, and outcome of chronic pancreatitis (CP) in black patients.

METHODS

We analyzed data on black patients with CP prospectively enrolled in the multicenter North American Pancreatitis Studies from 26 US centers during the years 2000-2014. CP was defined by definitive evidence on imaging studies or histology. Information on demographics, etiology, risk factors, disease phenotype, treatment, and perceived effectiveness was obtained from responses to detailed questionnaires completed by both patients and physicians.

RESULTS

Of the 1,159 patients enrolled, 248 (21%) were black. When compared with whites, blacks were significantly more likely to be male (60.9 vs. 53%), ever (88.2 vs. 71.8%), or current smokers (64.2 vs. 45.9%), or have a physician-defined alcohol etiology (77 vs. 41.9%). There was no overall difference in the duration of CP although for alcoholic CP, blacks had a longer duration of disease (8.6 vs. 6.97 years; P=0.02). Blacks were also significantly more likely to have advanced changes on pancreatic morphology (calcifications (63.3 vs. 55.2%), atrophy (43.2 vs. 34.6%), pancreatic ductal stricture or dilatation (72.6 vs. 65.5%) or common bile duct stricture (18.6 vs. 8.2%)) and function (endocrine insufficiency 39.9 vs. 30.2%). Moreover, the prevalence of any (94.7 vs. 83%), constant (62.6 vs. 51%), and severe (78.4 vs. 65.8%) pain and disability (35.1 vs. 21.4%) were significantly higher in blacks. Observed differences were in part related to variances in etiology and duration of disease. No differences in medical or endoscopic treatments were seen between races although prior cholecystectomy (31.1 vs. 19%) was more common in white patients.

CONCLUSIONS

Differences were observed between blacks and whites in the underlying cause, morphologic expression, and pain characteristics of CP, which in part are explained by the underlying risk factor(s) with alcohol and tobacco being much more frequent in black patients as well as disease duration.

Risk of Recurrent Pancreatitis and Progression to Chronic Pancreatitis After a First Episode of Acute Pancreatitis

BACKGROUND & AIMS

Patients with a first episode of acute pancreatitis can develop recurrent or chronic pancreatitis (CP). However, little is known about the incidence or risk factors for these events.

METHODS

We performed a cross-sectional study of 669 patients with a first episode of acute pancreatitis admitted to 15 Dutch hospitals from December 2003 through March 2007. We collected information on disease course, outpatient visits, and hospital readmissions, as well as results from imaging, laboratory, and histology studies. Standardized follow-up questionnaires were sent to all available patients to collect information on hospitalizations and interventions for pancreatic disease, abdominal pain, steatorrhea, diabetes mellitus, medications, and alcohol and tobacco use. Patients were followed up for a median time period of 57 months. Primary end points were recurrent pancreatitis and CP. Risk factors were evaluated using regression analysis. The cumulative risk was assessed using Kaplan-Meier analysis.

RESULTS

Recurrent pancreatitis developed in 117 patients (17%), and CP occurred in 51 patients (7.6%). Recurrent pancreatitis developed in 12% of patients with biliary disease, 24% of patients with alcoholic etiology, and 25% of patients with disease of idiopathic or other etiologies; CP occurred in 3%, 16%, and 10% of these patients, respectively. Etiology, smoking, and necrotizing pancreatitis were independent risk factors for recurrent pancreatitis and CP. Acute Physiology and Chronic Health Evaluation II scores at admission also were associated independently with recurrent pancreatitis. The cumulative risk for recurrent pancreatitis over 5 years was highest among smokers at 40% (compared with 13% for nonsmokers). For alcohol abusers and current smokers, the cumulative risks for CP were similar-approximately 18%. In contrast, the cumulative risk of CP increased to 30% in patients who smoked and abused alcohol.

CONCLUSIONS

Based on a retrospective analysis of patients admitted to Dutch hospitals, a first episode of acute pancreatitis leads to recurrent pancreatitis in 17% of patients, and almost 8% of patients progress to CP within 5 years. Progression was associated independently with alcoholic etiology, smoking, and a history of pancreatic necrosis. Smoking is the predominant risk factor for recurrent disease, whereas the combination of alcohol abuse and smoking produces the highest cumulative risk for chronic pancreatitis.

Acute Pancreatitis and Use of Pancreatitis-Associated Drugs: A 10-Year Population-Based Cohort Study

OBJECTIVES

To assess the use of acute pancreatitis (AP)-associated drugs in patients with AP, the relation between sales of these drugs and the incidence of AP, and the potential impact on AP severity and recurrence.

METHODS

All patients with incident AP between 2003 and 2012, in a well-defined area, were retrospectively identified. Data regarding AP etiology, severity, and recurrence and use of AP-associated drugs were extracted from medical records. Drugs were classified according to an evidence-based classification system. Annual drug sales data were obtained from the Swedish drug administration service.

RESULTS

Overall, 1457 cases of incident AP were identified. Acute pancreatitis-associated drug users increased from 32% in 2003 to 51% in 2012, reflecting increasing user rates in the general population. The incidence of AP increased during the study period but was not related to AP-associated drug user rates (P > 0.05). Recurrent AP occurred in 23% but was unrelated to AP-associated drug use (P > 0.05). In logistic regression analysis, after adjustment for comorbidity, AP-associated drug use was not related to AP severity (P > 0.05).

CONCLUSIONS

Use of AP-associated drugs is increasingly frequent in patients with AP. However, it does not have any major impact on the observed epidemiological changes in occurrence, severity, or recurrence of AP.

Acute pancreatitis

PURPOSE OF REVIEW

To summarize recent data on classification systems, cause, risk factors, severity prediction, nutrition, and drug treatment of acute pancreatitis.

RECENT FINDINGS

Comparison of the Revised Atlanta Classification and Determinant Based Classification has shown heterogeneous results. Simvastatin has a protective effect against acute pancreatitis. Young black male, alcohol, smoldering symptoms, and subsequent diagnosis of chronic pancreatitis are risk factors associated with readmissions after acute pancreatitis. A reliable clinical or laboratory marker or a scoring system to predict severity is lacking. The PYTHON trial has shown that oral feeding with on demand nasoenteric tube feeding after 72 h is as good as nasoenteric tube feeding within 24 h in preventing infections in predicted severe acute pancreatitis. Male sex, multiple organ failure, extent of pancreatic necrosis, and heterogeneous collection are factors associated with failure of percutaneous drainage of pancreatic collections.

SUMMARY

The newly proposed classification systems of acute pancreatitis need to be evaluated more critically. New biomarkers are needed for severity prediction. Further well designed studies are required to assess the type of enteral nutritional formulations for acute pancreatitis. The optimal minimally invasive method or combination to debride the necrotic collections is evolving. There is a great need for a drug to treat the disease early on to prevent morbidity and mortality.

Treating acute pancreatitis: what's new?

The medical treatment of acute pancreatitis continues to focus on supportive care, including fluid therapy, nutrition, and antibiotics, all of which will be critically reviewed. Pharmacologic agents that were previously studied were found to be ineffective likely due to a combination of their targets and flaws in trial design. Potential future pharmacologic agents, particularly those that target intracellular calcium signaling, as well as considerations for trial design will be discussed. As the incidence of acute pancreatitis continues to increase, greater efforts will be needed to prevent hospitalization, readmission and excessive imaging in order to reduce overall healthcare costs. Primary prevention continues to focus on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and secondary prevention on cholecystectomy for biliary pancreatitis as well as alcohol and smoking abstinence.

Severity and natural history of acute pancreatitis in diabetic patients

BACKGROUND

There is limited data on the prevalence of coexistent diabetes in acute pancreatitis and subsequent natural history in these patients.

METHODS

Using Pennsylvania Health Care Cost Containment Council data set, we identified 7399 unique White and Black Allegheny County, PA residents with first hospitalization for acute pancreatitis from 1996 to 2005. We evaluated the prevalence of coexistent diabetes, demographic and etiologic profile, severity of index hospitalization, and risk of readmission for acute or chronic pancreatitis during follow up (median 39 months) in this cohort.

RESULTS

The prevalence of coexisting diabetes was 18% (1349/7399). When compared with non-diabetics, diabetics were significantly more likely to be older (63 vs. 56 yrs), male (OR 1.4, 95% CI 1.2-1.6), black (OR 2.4, 95% CI 2.1-2.7) and have non-alcoholic etiologies (biliary, OR 1.5, 95% CI 1.2-1.9; idiopathic, OR 2.0, 95% CI 1.7-2.5; metabolic, OR 5.2, 95% CI 4.0-6.7). While diabetic patients had a significantly longer length of stay (median 5 vs. 4 days, p < 0.05), their severity of acute pancreatitis (multivariable OR 1.18, 95% CI 0.94-1.48) or in-hospital mortality (1.9% each, p = 0.98) did not differ than non-diabetics. The overall risk of pancreatitis-related readmissions in diabetics was similar (33% each, p = 0.99), but their risk of subsequent admission for chronic pancreatitis (multivariable HR 0.65, 95% CI 0.44-0.97) was lower than non-diabetics.

CONCLUSION

About 20% patients with acute pancreatitis have coexistent diabetes. Demographic and etiologic profile of diabetic patients with acute pancreatitis differs from non-diabetics. Diabetic status has limited effect on the severity of and natural history following acute pancreatitis.

Predictive factors for and incidence of hospital readmissions of patients with acute and chronic pancreatitis

BACKGROUND/OBJECTIVE

Acute and chronic pancreatitis are common gastroenterological disorders that have a fairly unpredictable long-term course often associated with unplanned hospital readmissions. Little is known about the factors that increase or decrease the risk for a hospital readmission. The aim of this study was to identify positive and negative predictive factors for hospital readmissions of patients with acute and chronic pancreatitis after in-hospital treatment.

METHODS

In a retrospective analysis data from the hospital information and reimbursement data system (HIS) were evaluated for 606 hospital stays for either acute or chronic pancreatitis between 2006 and 2011. Additional clinical data were obtained from a questionnaire covering quality of life and socio-economic status. A total of 973 patient variables were assessed by bivariate and multivariate analysis.

RESULTS

Between 2006 and 2011, 373 patients were admitted for acute or chronic pancreatitis; 107 patients of them were readmitted and 266 had only one hospitalization. Predictors for readmission were concomitant liver disease, presence of a pseudocyst or a suspected tumor of the pancreas as well as alcohol, tobacco or substance abuse or coexisting mental disorders. Patients who had undergone a CT-scan were more susceptible to readmission. Lower readmissions rates were found in patients with diabetes mellitus or gallstone disease as co-morbidity.

CONCLUSION

While factors like age and severity of the initial disease cannot be influenced to reduce the readmission rate for pancreatitis, variables like alcohol, tobacco and drug abuse can be addressed in outpatient programs to reduce disease recurrence and readmission rates for pancreatitis.

Risk of and factors associated with readmission after a sentinel attack of acute pancreatitis

BACKGROUND & AIMS

Few data are available on how many patients are readmitted to the hospital after attacks of acute pancreatitis. We aimed to determine the risk and factors that determine early (within 30 days) and late (after 30 days) readmission of patients with acute pancreatitis.

METHODS

In a retrospective study, we collected and analyzed data on 127 surviving patients (median age, 53 y; 52% male; 83% white) hospitalized at the University of Pittsburgh Medical Center for a sentinel attack of acute pancreatitis, enrolled in the Severe Acute Pancreatitis Study from June 2003 through April 2010, and who had follow-up data. Information was collected on demographics, clinical profile, risk score at discharge (based on a recently developed scoring system), and details of readmissions during the follow-up period (median, 36 mo).

RESULTS

Of the 127 patients, 52% were transfers from another care center and 32% required admission to the intensive care unit. Etiologies for pancreatitis were biliary (47%), idiopathic (13%), alcohol associated (12%), and others (28%). Pancreatic necrosis (28%), persistent organ failure (27%), and peripancreatic fluid collections (19%) were common. The median length of stay was 9 days. A total of 108 readmissions occurred for 43 patients (34%). Early readmissions (n = 21) occurred more frequently for patients with smoldering (ongoing) symptoms or local complications than for those without. Late readmissions (n = 22) occurred more frequently for patients with recurrent pancreatitis than for those without. Male sex, alcohol-associated disease, and severe disease increased the risks of readmission and recurrence. The risk for readmission was lower among nontransferred patients (23%) and patients without necrosis or organ failure (16%). Risk for readmission increased with the number of points on the weighted scoring system.

CONCLUSIONS

Approximately one-third of patients hospitalized for acute pancreatitis are readmitted, usually as a result of smoldering symptoms, local complications, or recurrent attacks. Studies are needed to determine whether individualized discharge planning, with consideration of the etiology of acute pancreatitis, can reduce the risk for readmission.