Comparing Charlson and Elixhauser comorbidity indices with different weightings to predict in-hospital mortality: an analysis of national inpatient data

Effects of the leisure-time physical activity environment on odds of glycemic control among a nationwide cohort of United States veterans with a new type-2 diabetes diagnosis

OBJECTIVE

This study examined associations between access to leisure-time physical activity (LTPA) facilities and parks and repeated measures of glycated hemoglobin (A1C) over time, using follow-up tests among United States Veterans with newly diagnosed type-2 diabetes (T2D).

METHODS

Data were analyzed from 274,463 patients in the Veterans Administration Diabetes Risk cohort who were newly diagnosed with T2D between 2008 and 2018 and followed through 2023. Generalized estimating equations with a logit link function and binomial logistic regression were used to examine associations.

RESULTS

Patients were on average 60.5 years of age, predominantly male (95.0 %) and white (66.9 %), and had an average of 11.7 A1C tests during the study follow-up period. In high- and low-density urban communities, a one-unit higher LTPA facility density score was associated with 1 % and 3 % greater likelihood of in-range A1C tests during follow-up, respectively, but no association was observed among patients living in suburban/small town and rural communities. Across community types, closer park distance was not associated with subsequent greater odds of in-range A1C tests. Unexpectedly, in low-density urban areas, the likelihood of in-range A1C tests was 1 % lower at farther park distances.

CONCLUSIONS

These results suggest that broader access to LTPA facilities, but not park proximity, may contribute in small ways to maintaining glycemic control after T2D diagnosis in urban communities. Tailored interventions may be needed to promote patients' effective use of LTPA facilities and parks.

Sex Differences and 2-Year Mortality in Patients With Atrial Fibrillation Diagnosed After Stroke and Known Atrial Fibrillation: A Register-Based Study in Sweden

BACKGROUND

The objective of this study was to determine associations between atrial fibrillation diagnosed after stroke (AFDAS) and known atrial fibrillation with 2-year mortality among men and women.

METHODS AND RESULTS

This longitudinal, register-based study included patients with ischemic stroke admitted to 3 hospitals in Gothenburg, Sweden, between November 1, 2014 and June 30, 2019. The exposures were known atrial fibrillation and AFDAS detected at the stroke units. The outcome was all-cause mortality 2 years after stroke. Cox-regression analyses were conducted to assess sex differences in relation to the adjusted mortality risk. Of 5468 patients with ischemic stroke, 2583 (47%) were women, and the mean age was 74 years (SD 14). Overall, 19% had known atrial fibrillation, and 10% had AFDAS. Women were older and had more severe strokes compared with men. Within the first month, women with AFDAS did not have an increased risk of mortality compared with women with no atrial fibrillation (hazard ratio, 0.93 [95% CI, 0.46-1.88]), in contrast to men with AFDAS who had an increased risk (hazard ratio, 2.14 [95% CI, 1.07-4.26]). Men and women with AFDAS had an increased risk of long-term mortality (31 days to 2 years) compared with those with no atrial fibrillation. Known atrial fibrillation was associated with the highest poststroke mortality irrespective of sex and time interval.

CONCLUSIONS

Our findings suggest that underlying sex differences exist in the association between the occurrence of AFDAS and poststroke mortality. Sex differences related to the timing of atrial fibrillation diagnosis should be considered when developing preventive measures and medical care after stroke.

Diagnostic yield of laboratory testing in hospitalized older adults with altered mental status

BACKGROUND

Altered mental status (AMS) is a common cause of hospitalization among older adults, with a wide range of potential etiologies. However, the diagnostic and therapeutic yield of routine laboratory testing in such patients is unknown.

METHODS

In a retrospective cohort of inpatient hospital admissions to a large academic medical center from 2017 to 2022 of patients 65 years and older for whom the admitting diagnosis was AMS, we assessed laboratory testing for thyroid stimulating hormone (TSH), syphilis, vitamin B12, folate, vitamin C, vitamin D, zinc, niacin, and thiamine. We calculated the frequency of testing, rate of abnormal results, and rate of follow-up treatment.

RESULTS

Of the 3169 patients, 2312 (73 %) received at least one designated lab, and overall, 12 % of labs were abnormal. Labs varied in frequency of use (0.2 % for niacin-66 % for TSH) and rate of abnormality (0 % for niacin-71 % for zinc). 16 % of abnormal index labs led to a new prescription at discharge. The most common tests - TSH, folate, and B12- were of relatively low diagnostic and therapeutic utility. Tests that were less common-zinc, vitamin D, and vitamin C-were more commonly abnormal. 3.8 % of patients tested for syphilis had abnormal results, and 72 % of patients with an abnormal result received treatment with penicillin during the index hospitalization.

CONCLUSIONS

These analyses suggest that commonly obtained labs in the workup of AMS have varied diagnostic and therapeutic utility. The contribution of observed laboratory abnormalities to a patients' AMS warrants further study to improve the delivery of high-value care.

The accuracy of an electronic-Surprise-Question defining end-of-life cohorts in a whole adult population by algorithmic digital risk stratification: the Proactive Risk-Based and Data-Driven Assessment of Patients at the End of Life (PRADA)

BACKGROUND

Current methods for identifying end-of-life cannot be applied systematically to large populations. We have developed, tested, validated a mortality probability algorithm with that level of scalability.

METHODS

This was a prospective whole adult population cohort study in Wolverhampton, a high deprivation, multiethnic city in the UK. Integrated hospital, community and primary care data spanned 2.5 years on 236,321 adults (age ≥18 years) including 6153 who had died. A binary logistic regression model (p < 0.001) generated mortality probability. This was triaged in a 2-step algorithm, based on care process measures and probability cut points. This digital enquiry, termed the e-Surprise-Question (e-SQ), allocated prognostic categories of e-SQ-Yes and e-SQ-No (>1, ≤1 year survival respectively). Those alive at baseline were followed prospectively (n = 230,168, e-SQ-Yes (n = 217,625), e-SQ-No (n = 12,543).

FINDINGS

At 12 months, mortality was 2753 (1.2%), with 1366 (0.6%) in e-SQ-Yes vs 1377 e-SQ-No (11.0%, 50% of all deaths, OR 19.4 (17.9-20.9), p < 0.001 (binary logistic regression)). The model's ROC c-statistic for 1-year mortality was 0.73 (0.72-0.74) (p < 0.001) and sensitivity, specificity, positive and negative predictive values 50.0%, 95.1%, 11.0%, and 99.4% respectively.

INTERPRETATION

This methodology is applicable at scale, anticipating mortality prognosis with statistical significance and clinically meaningful accuracy. The prognostic findings can be presented to clinicians for validation, further assessment and care planning for improved outcomes.

FUNDING

South Staffordshire Medical Centre Charitable Trust Rotha Abraham Bequest (Charity number 509324) and the Royal Wolverhampton NHS Trust Charity (Charity number 1059467).

Racial and Ethnic Disparities in Ischemic Stroke Severity in the National Inpatient Sample Between 2018 and 2021

BACKGROUND

The purpose of this study is to examine the association between race and ethnicity and ischemic stroke severity in the United States.

METHODS

We performed an analysis of adult hospital discharges in the National Inpatient Sample from 2018 to 2021 with a primary discharge diagnosis of ischemic stroke. We stratified our cohort based on self-reported race and ethnicity and evaluated stroke severity using the National Institutes of Health Stroke Scale. Age- and sex-adjusted estimates of the National Institutes of Health Stroke Scale were derived from linear regression models.

RESULTS

We included 231 396 stroke discharges with a mean National Institutes of Health Stroke Scale of 6.5±7.2. The cohort was 68.1% White, 17.4% Black, 8.2% Hispanic, and 6.3% other. The age- and sex-adjusted National Institutes of Health Stroke Scale for White patients was 6.25 (95% CI, 6.22-6.29), for Black patients was 7.12 (95% CI, 7.05-7.19), for Hispanic patients was 6.86 (95% CI, 6.76-6.97), and for patients of other races and ethnicities was 7.29 (95% CI, 7.18-7.41). Further adjustment for the Charlson Comorbidity Index, socioeconomic factors, and poorly controlled hypertension or diabetes did not significantly alter these findings.

CONCLUSIONS

In a large, contemporary, and nationally representative sample of patients with acute ischemic stroke, we show an association between non-White race and ethnicity and higher stroke severity. These results are concerning for an underappreciated health disparity in acute ischemic stroke.

Polygenic Resilience Scores are Associated With Lower Penetrance of Schizophrenia Risk Genes, Protection Against Psychiatric and Medical Disorders, and Enhanced Mental Well-Being and Cognition

BACKGROUND AND HYPOTHESIS

In the past decade, significant advances have been made in finding genomic risk loci for schizophrenia (SCZ). This, in turn, has enabled the search for SCZ resilience loci that mitigate the impact of SCZ risk genes. We identified the first genomic resilience profile for SCZ, completely independent from known risk loci for SCZ, though it remains unclear whether resilience loci foster protection against adverse states associated with SCZ involving clinical, cognitive, and brain-structural phenotypes.

STUDY DESIGN

We analyzed genomic and phenotypic data from 459 784 participants from the UK Biobank, using regression models to estimate interaction effects of resilience and SCZ risk scores on phenotypes spanning multiple scales.

STUDY RESULTS

We found that resilience loci for SCZ afforded protection against lifetime psychiatric (schizophrenia, bipolar disorder, anxiety, and depression) and medical disorders (such as type 2 diabetes, cardiovascular, and digestive and metabolic disorders). Resilience loci also moderated the impact of SCZ loci, associated with protection against self-harm behavior and greater fluid intelligence scores. The main effects of resilience are also observed in the absence of a moderating effect in some instances, such as associations with larger brain structures.

CONCLUSIONS

Overall, this study highlights a wide range of phenotypes that are significantly associated with resilience loci within the general population, revealing distinct patterns separate from those associated with SCZ risk loci. Resilience loci may protect against serious psychiatric and medical outcomes, comorbidities, and cognitive impairment. Therefore, it is conceivable that resilience loci facilitate adaptive processes linked to improved health and life expectancy.

Data-driven insights into interhospital care fragmentation: Implications for health policy and equity among older adults

OBJECTIVE

To determine factors leading to interhospital care fragmentation (ICF); evaluate how ICF affects rehospitalization costs, length of stays (LOS), and delayed discharge; and analyze ICF disparity among equity-seeking groups.

MATERIALS AND METHODS

We used a 13-year retrospective cohort of older adults (65+) in Ontario, Canada. Utilizing multivariable logistic regression, we identified characteristics associated with ICF and determined its association with outcomes.

RESULTS

Discharge to facilities except home and homecare and travel distance were the strongest risk factors for ICF. Patients were less likely to experience ICF if they were older, frail, or had multiple comorbidities. ICF was strongly associated with an increase in the daily costs of readmission. Moreover, the risks of a prolonged LOS after ICF and delayed discharge were higher among returning surgical patients. The rural residency was a source of health inequality.

CONCLUSIONS

ICF exacerbates health disparities and worsens patient outcomes. Our study identified several risk factors associated with ICF, some of which are controllable, paving the way for interventions to mitigate this issue. To promote health equity and reduce adverse outcomes, policymakers should focus on policies for reducing care discontinuity, particularly addressing the controllable risk factors.

Clinical Outcomes of Gender-Affirming Surgery in Individuals With Connective Tissue Disorders

INTRODUCTION

Gender-affirming surgery (GAS) is a complex process that often requires multiple surgical operations and carries a complication risk that could be exacerbated by connective tissue disorders (CTDs). This study aims to investigate the association between CTD diagnosis and GAS outcomes.

METHODS

Using the Merative MarketScan Research Databases, patients with gender dysphoria diagnoses who underwent GAS between 2007 and 2022 were identified. Among these, patients with diagnosed CTDs were identified. Demographics, comorbidities, and postoperative complications were recorded. Chi-squared, Shapiro-Wilk, Wilcoxon-Mann-Whitney, and multivariate logistic regression testing was used for statistical analysis.

RESULTS

Of 7575 patients meeting criteria (mean age 29 ±10 years), 300 (4%) had CTD diagnoses. One or more postoperative complications were recorded in 9.8% of patients, without statistically significant difference between CTD and non-CTD patients. Additional simultaneous GAS procedures [odds ratio (OR) 2.02; P < 0.01], Elixhauser index scores of 3+ (OR 1.36; P = 0.010), and age >45 years (OR 1.47; P = 0.02) increased odds of experiencing complications following the index GAS procedure, while CTD diagnoses (P = 0.52) did not affect odds of experiencing complications. However, CTD diagnoses did elevate odds of readmission (OR 1.47; P = 0.046), as did multiple simultaneous GAS procedures (OR 2.66), Elixhauser index scores of 3+ (OR 3.72), and smoking (OR 2.18) (P < 0.01).

CONCLUSIONS

These findings suggest CTDs may impact some gender-affirming surgical outcomes, and careful preoperative evaluation and management of comorbidities is necessary to reduce the risk of complications and readmission in this population. Surgeons should continue to exercise caution when performing elective surgery on patients taking immunomodulatory medications.

Outcomes After Surgical Management of Early-Stage Lung Cancer in Octogenarians: An In-Depth Analysis of a Nationally Representative Cohort

INTRODUCTION

As the United States population ages more octogenarians are undergoing surgical resection for lung cancer. We aimed to provide an updated and expanded assessment of age-related risks associated with surgical resections for early-stage NSCLC.

METHODS

The Surveillance, Epidemiology, and End Results and Medicare databases were queried for stage IA NSCLC cases treated by surgery between 2006 and 2018. Analyses included generalized linear models for one-year mortality and Cox proportional hazards models for five-year survival.

RESULTS

One-year all-cause mortality among 4061 octogenarians was more than double that of the youngest group (age: 65-69 y): 15.2% versus 7.3%, p value less than 0.001. Octogenarians were discharged to extended skilled nursing facility stays more than three times as often as the youngest group (19.9% versus 6.3%, p < 0.001). For those with skilled nursing facility duration greater than 30 days, there was a 36% greater one-year mortality risk compared with those discharged to home or home-health. In adjusted analyses, octogenarians had 62% greater one-year mortality risk compared with those aged below 80 years (risk ratio = 1.62, 95% confidence interval: 1.48-1.78). The risk of death within five years was 52% higher (hazard ratio = 1.52, 95% confidence interval: 1.42-1.62). Additional factors associated with one-year mortality included male sex, higher comorbidity burden, lower county median income, open approach, and sub-lobar resection.

CONCLUSIONS

This analysis provides an updated and expanded characterization of age-related outcomes on the basis of a large national cohort representative of elderly patients treated outside of clinical trials. Substantial gaps in survival and discharge disposition motivate further research and the development of interventions to help improve outcomes in older patients.

First Clinical Evidence About the Use of a New Silver-Coated Titanium Alloy Instrumentation to Counteract Surgical Site Infection at the Spine Level

Background: Surgical site infections (SSIs) following spinal instrumentation surgery are among the most concerning complications. This study is aimed at assessing the effectiveness of a new treatment approach for SSIs that includes a single-stage approach with the removal of the previous hardware, accurate debridement, and single-stage instrumentation using a silver fixation system (SFS) made of titanium alloy coated with silver (Norm Medical, Ankara, Turkey) by means of a retrospective observational study. Materials and Methods: The demographic data, type of surgery, comorbidities, pathogens, and treatment details of consecutive patients with an SSI who received the SFS between 2018 and 2021 were extracted from their medical records and analyzed. The patients treated with the SFS for primary pyogenic infections were excluded. The patients were re-evaluated at multiple endpoints in order to assess the rate of reinfection and the local and general complications. Results: Fifty-six patients were treated with the SFS and thirty-four patients met the inclusion criteria. Out of those 34 patients, the rate of infection recurrence or insurgence after the implantation of the SFS was 11.8%, with infection detected in 4 out of 34 cases and mechanical problems detected in 2 of the 34 cases (5.9%). The overall success rate in controlling infection recurrence or emergence was 88.2% (30 out of 34 cases). The overall survival rate of the SFS was 87%, 78%, and 71% at one, two, and three years, respectively. Conclusions: The surgical strategy with the SFS demonstrated promising outcomes in preventing infection recurrence or insurgence, with a low incidence of mechanical complications. However, further structured and comprehensive studies are essential for validating these initial findings.

Patient Complexity, Social Factors, and Hospitalization Outcomes at Academic and Community Hospitals

Importance

There have been limited evaluations of the patients treated at academic and community hospitals. Understanding differences between academic and community hospitals has relevance for the design of clinical models of care, remuneration for clinical services, and health professional training programs.

Objective

To evaluate differences in complexity and clinical outcomes between patients admitted to general medical wards at academic and community hospitals.

Design, Setting, and Participants

This retrospective cohort study of patients admitted to general medicine at 28 hospitals in Ontario, Canada, was conducted between April 2015 and December 2021. All patients admitted to or discharged from general medicine during the study period who were older than 18 years were included. Data analysis occurred between February 2023 and June 2024.

Exposures

Patient admission to a general medicine inpatient service at an academic or community hospital.

Main Outcomes and Measures

Demographic and clinical characteristics (age, sex, modified Laboratory-based Acute Physiology Score [mLAPS], discharge diagnosis, Charlson Comorbidity Index, frailty risk score, and disability), social factors (neighborhood-level markers of income, material deprivation, immigrant status, and racial and ethnic minority status) and clinical outcomes and processes (patient volume per physician, in-hospital mortality, length of stay, readmission rates, and intensive care unit [ICU] admission rates).

Results

There were 947 070 admissions, including 609 696 at 17 community hospitals (median [IQR] age, 73 [58-84] years) and 337 374 at 11 academic hospitals (median [IQR] age, 70 [56-82] years). Baseline clinical characteristics were similar at community and academic hospitals, including female sex (307 381 [50.4%] vs 168 033 [49.8%]; standardized mean difference [SMD] = 0.012), median (IQR) mLAPS (21 [11-36] vs 21 [10-34]; SMD = 0.001), and Charlson Comorbidity Index score of 2 or greater (182 171 [29.9%] vs 105 502 [31.3%]; SMD = 0.038). Social characteristics, including income, education, and neighborhood proportion of racial and ethnic minority and immigrant residents were also similar. The number of unique discharge diagnoses was similar at academic and community hospitals. Patient volumes per attending physician were higher at academic hospitals (median [IQR] daily census, 20 [19-22] vs 17 [15-19]; SMD = 1.086). After multivariable regression adjusting for baseline factors, mortality (adjusted odds ratio [aOR], 0.96; 95% CI, 0.78 to 1.17), ICU admission rate (aOR, 1.20; 95% CI, 0.80 to 1.79) and length of stay (β =  -0.001; 95% CI, -0.10 to 0.10) were not significantly different, while 7-day readmission (aOR, 1.25; 95% CI, 1.10 to 1.43) and 30-day readmission (aOR, 1.25; 95% CI, 1.10 to 1.42) were significantly higher at academic hospitals than community hospitals.

Conclusions and Relevance

In this cohort study, patients admitted to general medicine at academic and community hospitals had similar baseline clinical characteristics and generally similar clinical outcomes, with greater readmission rates in academic hospitals. These findings suggest that the patient case mix in general internal medicine that trainees would be exposed to during their residency training at academic hospitals is largely representative of the case mix they would encounter at community hospitals, and has important implications for health services planning and funding.

Incorporating clinical and demographic data into the Elixhauser Comorbidity Model: deriving and validating an enhanced model in a tertiary hospital's internal medicine department

BACKGROUND AND OBJECTIVES

The Elixhauser Comorbidity Model is a prominent, freely-available risk adjustment model which performs well in predicting outcomes of inpatient care. However, because it relies solely on diagnosis codes, it may not capture the full extent of patient complexity. Our objective was to enhance and validatethe Elixhauser Model by incorporating additional clinical and demographic data to improve the accuracy of outcome prediction.

METHODS

This retrospective observational cohort study included 55,945 admissions to the internal medicine service of a large tertiary care hospital in Jerusalem. A model was derived and validated to predict four primary outcomes. The four primary outcomes measured were length of stay (LOS), in-hospital mortality, readmission within 30 days, and increased care.

RESULTS

Initially, the Elixhauser Model was applied using standard Elixhauser definitions based on diagnosis codes. Subsequently, clinical variables such as laboratory test results, vital signs, and demographic information were added to the model. The expanded models demonstrated improved prediction compared to the baseline model. For example, the R2 for log LOS improved from 0.101 to 0.281 and the c-statistic to predict in-hospital mortality improved from 0.711 to 0.879.

CONCLUSIONS

Adding readily available clinical and demographic data to the base Elixhauser model improves outcome prediction by a considerable margin. This enhanced model provides a more comprehensive representation of patients' health status. It could be utilized to support decisions regarding admission and to what setting, determine suitability for home hospitalization, and facilitate differential payment adjustments based on patient complexity.

Impact of Precision in Staging Acute Kidney Injury and Chronic Kidney Disease on Treatment Outcomes: An Observational Study

(1) Background: "Kidney Disease: Improving Global Outcomes" (KDIGO) provides guidelines for identifying the stages of acute kidney injury (AKI) and chronic kidney disease (CKD). A data-driven rule-based engine was developed to determine KDIGO staging compared to KD-related keywords in discharge letters. (2) Methods: To assess potential differences in outcomes, we compare the patient subgroups with exact KDIGO staging to imprecise or missing staging for all-cause mortality, in-hospital mortality, selection bias and costs by applying Kaplan-Meier analysis and the Cox proportional hazards regression model. We analysed 63,105 in-patient cases from 2016 to 2023 at a tertiary hospital with AKI, CKD and acute-on-chronic KD. (3) Results: Imprecise and missing CKD staging were associated with an 85% higher risk of all-cause and in-hospital mortality (CI: 1.7 to 2.0 and 1.66 to 2.03, respectively) compared to exact staging for any given disease status; imprecise or missing AKI staging increased in-hospital mortality risk by 56% and 57% (CI: 1.43 to 1.70 and 1.37 to 1.81, respectively) in patients with AKI. (4) Conclusions: Exact staging is associated with better outcomes in KD management. Our study provides valuable insight into potential quality and outcome improvements and lower costs, considering elderly patients, women and patients with acute-on-chronic KD as the most vulnerable.

Clinical frailty and short-term outcomes after low-energy pelvic fracture in the geriatric population: Nationwide inpatient sample 2016-2018 analysis

BACKGROUND

Pelvic fractures can be life-threatening for elderly individuals with diminished bone strength. Frailty is associated with fracture outcomes, but its impact on pelvic fracture recovery remains unexplored. The aim of this study was to investigate the association between frailty and short-term outcomes in older adults hospitalized for low-energy pelvic fractures.

METHODS

Data from the Nationwide Inpatient Sample (NIS) covering the years 2005 to 2018 were reviewed. Inclusion criteria were age ≥ 60 years admitted for a low-energy pelvic fracture. Patients were categorized into frail and non-frail groups using the 11-factor modified Frailty Index (mFI-11). Association between frailty and in-hospital outcomes were determined by univariate and multivariable regression analyses.

RESULTS

A total of 24,688 patients with pelvic fractures were included. The mean patient age was 80.6 ± 0.1 years, and 35 % were classified as frail. After adjustments, frailty was significantly associated with unfavorable discharge (adjusted odds ratio [aOR] = 1.07, 95 % confidence interval [CI]: 1.00-1.15, p = 0.038), prolonged hospitalization (aOR = 1.51, 95 % CI: 1.41-1.62, p < 0.001), complications (aOR = 1.42, 95 % CI:1.34-1.50, p < 0.001), and acute kidney injury (aOR = 1.68, 95 % CI: 1.56-1.82, p < 0.001). Stratified analyses based on age and fracture type showed frailty was consistently associated with adverse outcomes.

CONCLUSIONS

Persons ≥60 years old with mFI-11 assessed frailty and a low-energy pelvic fracture are at higher risk of adverse in-hospital outcomes than non-frail patients. Additional research is needed to disclose the prognostic impact of clinical frailty on long-term functional outcomes and quality of life after discharge.

The Impact of Opioid Prescription on the Occurrence and Outcome of Pneumonia: A Nationwide Cohort Study in South Korea

BACKGROUND

Opioids are known to cause respiratory depression, aspiration, and to suppress the immune system. This study aimed to investigate the relationship between short- and long-term opioid use and the occurrence and clinical outcomes of pneumonia in South Korea.

METHODS

The data for this population-based retrospective cohort analysis were obtained from the South Korean National Health Insurance Service. The opioid user group consisted of those prescribed opioids in 2016, while the non-user group, who did not receive opioid prescriptions that year, was selected using a 1:1 stratified random sampling method. The opioid users were categorized into short-term (1-89 d) and long-term (≥90 d) users. The primary end point was pneumonia incidence from January 1, 2017-December 31, 2021, with secondary end points including pneumonia-related hospitalizations and mortality rates during the study period.

RESULTS

In total, 4,556,606 adults were enrolled (opioid group, 2,070,039). Opioid users had a 3% higher risk of pneumonia and an 11% higher risk of pneumonia requiring hospitalization compared to non-users. Short-term users had a 3% higher risk of pneumonia, and long-term users had a 4% higher risk compared to non-users (P < .001). Additionally, short-term users had an 8% higher risk of hospital-treated pneumonia, and long-term users had a 17% higher risk compared to non-users (P < .001).

CONCLUSIONS

Both short- and long-term opioid prescriptions were associated with higher incidences of pneumonia and hospital-treated pneumonia. In addition, long-term opioid prescriptions were linked to higher mortality rates due to pneumonia.

The value of Age-adjusted Charlson and Elixhauser-Van Walraven comorbidity index in predicting prognosis for patients undergoing heart valve surgery

OBJECTIVE

This study aims to compare the efficacy of the Age-adjusted Charlson Comorbidity Index (ACCI) and the Elixhauser-Van Walraven Comorbidity Index (ECI-VW) in predicting mortality risk among patients undergoing heart valve surgery.

METHODS

Clinical data were extracted from the INSPIRE Database using R language. The Receiver Operating Characteristic (ROC) Curve was employed to assess the predictive accuracy of ACCI and ECI-VW for in-hospital all-cause mortality and post-surgical all-cause mortality at 7 and 28 days. Subgroup analysis was conducted to validate the application efficacy, and the optimal cutoff value was identified.

RESULTS

The study included 996 patients, with 931 survivors and 65 cases of in-hospital all-cause mortality. The area under the curve (AUC) for ACCI in predicting in-hospital all-cause mortality was 0.658 (95% CI: 0.584, 0.732), while the AUC for ECI-vw in predicting the same outcome was 0.663 (95% CI: 0.584, 0.741). For predicting all-cause mortality within 7 days post-surgery, the AUC of ACCI was 0.680 (95% CI: 0.04, 0.56), and for ECI-vw, it was 0.532 (95% CI: 0.353, 0.712). Regarding the prediction of all-cause mortality within 28 days after surgery, the AUC for ACCI was 0.724 (95% CI: 0.622, 0.827), and for ECI-vw, it was 0.653 (95% CI: 0.538, 0.69). Patients were categorized into two groups based on the ACCI cutoff value of 3.5, including Group 1 (ACCI < 3.5 points, 823 cases) and Group 2 (ACCI > 3.5 points, 173 cases). The overall survival rate for these two patient groups was calculated using the Kaplan-Meier method, revealing that the 28-day postoperative survival rate for patients in Group 1 was significantly higher than that for patients in Group 2 (P < 0.0001).

CONCLUSIONS

ACCI demonstrates significant predictive value for in-hospital all-cause mortality within 28 days following cardiac valve disease surgery. Patients presenting with an ACCI greater than 3.5 exhibit an increased risk of mortality within 28 days post-surgery compared to those with an ACCI less than 3.5. This finding suggests that the ACCI can serve as a preliminary tool for assessing the prognosis of patients undergoing this type of surgical intervention.

Procedure Prioritization During a Nationwide Ban on Non-Urgent Healthcare: A Quasi-Experimental Retrospective Study of Hospital Data in Switzerland

Background

During the COVID-19 lockdown in spring 2020, Switzerland restricted non-urgent healthcare services to safeguard capacity. While prioritization of care was supposed to be driven by medical urgency, demographic factors or economic incentives might have influenced the hospitals' resource allocation decisions.

Objectives

This study investigates potential determinants of procedure prioritization in hospitalized patients during the lockdown period.

Design

Quasi-experimental retrospective study of hospital data in Switzerland.

Methods

We analyzed 496 456 adult patients with known insurance status and a recorded procedure, admitted for cardiovascular, orthopedic/musculoskeletal or oncological reasons from January 2017 (3 years before the COVID-19 outbreak) to mid-April 2020 (in the first year of the COVID-19 pandemic), to obtain admission rate ratios (ARRs, "lockdown" admission rates divided by "normal" rates) from negative binomial regression analysis of fortnightly admissions for frequent procedure-diagnosis combinations. Quade and Wilcoxon signed-rank tests compared ARRs between sex×age, insurance and comorbidity strata.

Results

Admission rates showed significant reductions for 29 of 53 procedure-diagnosis combinations. Reductions varied strongly by emergency, with largest decreases in orthopedic procedures for arthrosis (osteoarthritis) and non-arthritic joint disorders, and the smallest in cerebral imaging for stroke patients and surgical procedures for malignant neoplasms. The only difference in ARRs between strata was a stronger decrease in admission rates for cardiovascular combinations for patients with private versus basic health insurance.

Conclusion

While medical procedures were affected to varying degrees by the ban on non-urgent healthcare during the COVID-19 lockdown, we found no robust evidence that factors other than medical urgency influenced healthcare prioritization.

Comparison of the effectiveness of open, laparoscopic, and robotic-assisted radical prostatectomies based on complication rates: a retrospective observational study with administrative data from Switzerland

BACKGROUND

Radical prostatectomies can be performed using open retropubic, laparoscopic, or robot-assisted laparoscopic surgery. The literature shows that short-term outcomes (in particular, inpatient complications) differ depending on the type of procedure. To date, these differences have only been examined and confirmed in isolated cases based on national routine data.

METHODS

The data was based on the Swiss Medical Statistics from 2016 to 2018 from a national survey of administrative data from all Swiss hospitals. Cases with the coded main diseases neoplasm of the prostate (ICD C61) and the main treatments of laparoscopic (CHOP 60.5X.20) or retropubic (CHOP 60.5X.30) radical prostatectomies were included, resulting in a total sample size of 8,593 cases.

RESULTS

A procedure-related complication occurred in 998 cases (11.6%). By surgical procedure, complication rates were 10.1% for robotic-assisted laparoscopic radical prostatectomy 9.0% for conventional laparoscopic radical prostatectomy and 17.1% for open retropubic radical prostatectomy (p < 0.001). Conventional and robotic-assisted laparoscopic radical prostatectomies had a significantly lower risk of complications than retropubic procedures. Moreover, the risk of a procedure-related complication was almost twice as high in cases operated on retropubically; however, no significant difference was found between conventional and robotic-assisted laparoscopic cases.

DISCUSSION

The use of a surgical robot showed no advantages in radical prostatectomies regarding procedure-related during the hospital stay. However, both conventional and robotic-assisted laparoscopically operated radical prostatectomies show better results than open retropubic procedures. Further studies on the long-term course of patients based on claims data are needed to confirm the inherent benefits of surgical robots in tandem with them being increasingly employed in hospitals.

Discrepancy between estimated glomerular filtration rate by creatinine versus cystatin C in different patient care settings

OBJECTIVE

Estimated glomerular filtration rate (eGFR) calculated by cystatin C (cysC) has been recommended for broader adoption. This study assessed the discrepancy between eGFR calculated by cysC (eGFRcys) and creatinine (eGFRcr) in different patient care settings and explored potential contributing factors to such discrepancies.

METHODS

This retrospective study included 2072 patients with paired cysC and creatinine results in different patient care settings. Delta eGFRcr-cys (eGFRcr - eGFRcys) was analyzed in relationship to patient care settings and the Elixhauser Comorbidity index. The 90-day survival in patients with different delta eGFR was assessed by Kaplan-Meier analysis, univariate and multivariate Cox proportional hazard models. In addition, discrepancy between eGFRcys and eGFRcr was analyzed in 50 ambulatory patients with systemic inflammation but normal kidney function.

RESULTS

Inpatients had higher cysC (median 1.91 mg/L), lower eGFRcys (median 31 mL/min/1.73 m2), and larger delta eGFRcr-cys (median 18 mL/min/1.73 m2) than outpatients (cysC median 1.53 mg/L, p < 0.0001, eGFRcys median 41 mL/min/1.73 m2, p < 0.0001, delta eGFRcr-cys median 4 mL/min/1.73 m2, p < 0.0001). Higher Elixhauser Comorbidity index correlated with lower eGFRcys and larger delta eGFRcr-cys, with median delta eGFRcr-cys 11 and 6 mL/min/1.73 m2 in patients with a Comorbidity index > 15 and ≤ 15, respectively (p < 0.0001). Increased delta eGFRcr-cys was associated with worse 90-day survival. Patients with systemic inflammation but normal kidney function had lower eGFRcys (median 77.5 mL/min/1.73 m2) than eGFRcr (median 97 mL/min/1.73 m2, p < 0.001), with red blood cell abnormalities as associated factors.

CONCLUSION

Inflammation and comorbidities are associated with decreased eGFRcys and large discrepancies between eGFRcr and eGFRcys independent of kidney function and are most apparent in inpatients. Creatinine-cysC combined eGFR reduces this discrepancy and should be broadly adopted.

Association Between Oral Anticoagulant Adherence and Serious Clinical Outcomes in Patients With Atrial Fibrillation: A Long-Term Retrospective Cohort Study

BACKGROUND

Patients with atrial fibrillation are frequently nonadherent to oral anticoagulants (OACs) prescribed for stroke and systemic embolism (SSE) prevention. We quantified the relationship between OAC adherence and atrial fibrillation clinical outcomes using methods not previously applied to this problem.

METHODS AND RESULTS

Retrospective observational cohort study of incident cases of atrial fibrillation from population-based administrative data over 23 years. The exposure of interest was proportion of days covered during 90 days before an event or end of follow-up. Cox proportional hazard models were used to evaluate time to first SSE and the composite of SSE, transient ischemic attack, or death and several secondary outcomes. A total of 44 172 patients were included with median follow-up of 6.7 years. For direct OACs (DOACs), each 10% decrease in adherence was associated with a 14% increased hazard of SSE and 5% increased hazard of SSE, transient ischemic attack, or death. For vitamin K antagonist (VKA) the corresponding increase in SSE hazard was 3%. Receiving DOAC or VKA was associated with primary outcome hazard reduction across most the proportion of days covered spectrum. Differences between VKA and DOAC were statistically significant for all efficacy outcomes and at most adherence levels.

CONCLUSIONS

Even small reductions in OAC adherence in patients with atrial fibrillation were associated with significant increases in risk of stroke, with greater magnitudes for DOAC than VKA. DOAC recipients may be more vulnerable than VKA recipients to increased risk of stroke and death even with small reductions in adherence. The worsening efficacy outcomes associated with decreasing adherence occurred without the benefit of major bleeding reduction.

A New Start with HAART: Evaluating Breast Reconstruction in the Era of Highly Active Antiretroviral Therapy

Background

As HIV-positive individuals utilizing highly active antiretroviral therapy live longer, the burden of breast cancer increases in the population. Breast reconstruction is an integral aspect of surgical treatment for many patients after a breast cancer diagnosis, prompting this examination of the characteristics and outcomes of breast reconstruction in this growing patient population.

Methods

Using Merative MarketScan Research Databases, a large multipayer database, HIV-positive adult patients who underwent autologous or implant-based breast reconstruction between 2007 and 2021 were identified using International Classification of Disease codes and Common Procedural Terminology codes. In both HIV-positive and -negative cohorts, patient demographics, procedure-related complications, and postoperative revisions were recorded. Shapiro-Wilk, chi-square, Wilcoxon-Mann-Whitney, and multivariable logistic regression tests were used for statistical analysis.

Results

Of 173,421 patients who underwent breast reconstruction, 1816 had an HIV diagnosis. HIV-positive patients were younger (P < 0.001), underwent surgery more recently (P < 0.001), more often underwent immediate breast reconstruction (P < 0.001), and had higher comorbidity levels (P < 0.001). There was a regional variation in which the patient cohorts underwent breast reconstruction. There was no significant difference in overall complication rates between patient groups, but HIV-negative patients more often underwent revision procedures (P = 0.009).

Conclusions

When compared to their HIV-negative counterparts, breast reconstruction can be considered safe and efficacious in patients living with HIV. HIV-positive patients are a growing demographic who seek breast reconstruction, and surgeons must continue to further understand the unique implications of breast reconstruction in this population.

Enhancing the quality of evidence, comparability, and reproducibility in ventriculoatrial shunt research for normal pressure hydrocephalus: A systematic review and VAS-NPH reporting guideline

BACKGROUND

Ventriculoatrial shunt (VAS) is an important treatment option for normal pressure hydrocephalus (NPH). However, clinical studies reporting the use of VAS for NPH lack sufficient standardization for meta-analytic comparisons that could provide robust evidence regarding its use. This study aims to assess the quality of reporting in these studies and develop a reporting guideline checklist to standardize terminology, concepts, and reporting while reinforcing the essential elements to ensure comparability and reproducibility.

METHODS

This is a systematic literature review that followed the PRISMA guidelines with the search in Medline, Embase, and Web of Science databases, with no timeframe restriction. The level of evidence of the studies was assessed using the GRADE system, and the rigor used in the publication of the results was assessed concerning adherence to the guidelines indicated by the EQUATOR Network Group. Furthermore, the studies were scrutinized focusing on eight domains: (1) Characteristics of the included studies and baseline characteristics of the patients; (2) Reporting methodology; (3) Pivotal concepts definition; (4) Adverse events assessment; (5) Data writing and reporting; (6) Detailed outcomes reporting; (7) Specific clinical outcomes assessment and reporting; and (8) Complications reporting.

RESULTS

A total of 14 studies with 734 patients and 753 shunts were included in this review, and the assessment exposes notable deficiencies in reporting, specifically in baseline patient details, methodology, and outcome assessments. Only two studies followed reporting guidelines, prompting concerns about comprehensive reporting of adverse events and intraoperative complications. Varied reporting completeness existed for shunt-related issues. The absence of standardized definitions for key concepts and insufficient intervention details were observed. A VAS-NPH reporting guideline, encompassing 36 items across eight domains, was developed to address these shortcomings.

CONCLUSION

This systematic review reveals significant deficiencies in methodological rigor and reporting quality. The proposed VAS-NPH Reporting Guideline covers all essential aspects and is a potential solution to rectify these shortcomings and increase transparency, comparability, and reproducibility. This initiative aims to advance the level of evidence and enhance knowledge regarding the use of VAS in NPH.

Multi-year population-based analysis of Asian patients with acute decompensated heart failure and advanced chronic kidney disease

BACKGROUND

Data on disparities in outcomes and risk factors in Asian patients with advanced chronic kidney disease admitted for heart failure are scare.

METHODS

This was a retrospective cohort study that utilized data from the National Inpatient Sample between January 2016 and December 2019. Patients who had a primary diagnosis of acute decompensated heart failure and a concomitant diagnosis of advanced CKD were included. The primary outcome of interest was in-hospital mortality. Secondary outcomes include hospital cost, length of stay, and other clinical outcomes. Weighted multivariable logistic regression was used to adjust for comorbidities.

RESULTS

There were 251,578 cases of ADHF with advanced CKD, out of which 2.6 % were from individuals of Asian ethnicity. Asian patients exhibited a higher burden of comorbidities in comparison to other UREM patients, but a lower burden than White patients. Regardless of differences in comorbidity burden, Asian patients exhibited a higher likelihood of experiencing severe consequences. After adjusting for comorbidies, White (OR:1.11; 95 % CI 1.03-1.20;0.009) patients had higher odds of mortality than Asian patients. However, Blacks (OR: 0.58; 95 % CI 0.53 to 0.63; p < 0.001) and Hispanics (OR: 0.69; 95 % CI 0.62 to 0.78; p < 0.001) had lower odds of mortality.

CONCLUSION

This first population-based studies shows that Asian patients with advanced CKD admitted for ADHF have greater comorbidity burden and poorer outcomes Black and Hispanic patients. This data underscores the importance of comprehensive approaches in phenotyping, and ethnic specific interventions.

Implementation of an "opt-out" tobacco treatment program in six hospitals in South Carolina

OBJECTIVE

Describe the screening, referral, and treatment delivery associated with an opt-out tobacco treatment program (TTP) implemented in six hospitals varying in size, rurality and patient populations.

METHODS

Between March 6, 2021 and December 17, 2021, adult patients (≥ 18 years) admitted to six hospitals affiliated with the Medical University of South Carolina were screened for smoking status. The hospitals ranged in size from 82 to 715 beds. Those currently smoking were automatically referred to one of two tobacco treatment options: 1) Enhanced care (EC) where patients could receive a bedside consult by a trained tobacco treatment specialist plus an automated post-discharge follow-up call designed to connect those smoking to the South Carolina Quitline (SCQL); or 2) Basic care (BC) consisting of the post-discharge follow-up call only. An attempt was made to survey patients at 6-weeks after hospitalization to assess smoking status.

RESULTS

Smoking prevalence ranged from 14 to 49% across the six hospitals; 6,000 patients were referred to the TTP.The delivery of the bedside consult varied across the hospitals with the lowest in the Charleston hospitals which had the highest caseload of referred patients per specialist. Among patients who received a consult visit during their hospitalization, 50% accepted the consult, 8% opted out, 3% claimed not to be current smokers, and 38% were unavailable at the time of the consult visit. Most of those enrolled in the TTP were long-term daily smokers.Forty-three percent of patients eligible for the automated post-discharge follow-up call answered the call, of those, 61% reported smoking in the past seven days, and of those, 34% accepted the referral to theSCQL. Among the 986 of patients surveyed at 6-weeks after hospitalization quit rates ranged from 20%-30% based on duration of reported cessation and were similar between hospitals and for patients assigned to EC versus BC intervention groups.

CONCLUSION

Findings demonstrate the broad reach of an opt-out TTP. Elements of treatment delivery can be improved by addressing patient-to-staffing ratios, improving systems to prescribe stop smoking medications for patients at discharge and linking patients to stop smoking services after hospital discharge.

Incidence and mortality of community-acquired and nosocomial infections in Japan: a nationwide medical claims database study

BACKGROUND

It is important to determine the prevalence and prognosis of community-acquired infection (CAI) and nosocomial infection (NI) to develop treatment strategies and appropriate medical policies in aging society.

METHODS

Patients hospitalized between January 2010 and December 2019, for whom culture tests were performed and antibiotics were administered, were selected using a national claims-based database. The annual trends in incidence and in-hospital mortality were calculated and evaluated by dividing the patients into four age groups.

RESULTS

Of the 73,962,409 inpatients registered in the database, 9.7% and 4.7% had CAI and NI, respectively. These incidences tended to increase across the years in both the groups. Among the patients hospitalized with infectious diseases, there was a significant increase in patients aged ≥ 85 years (CAI: + 1.04%/year and NI: + 0.94%/year, P < 0.001), while there was a significant decrease in hospitalization of patients aged ≤ 64 years (CAI: -1.63%/year and NI: -0.94%/year, P < 0.001). In-hospital mortality was significantly higher in the NI than in the CAI group (CAI: 8.3%; NI: 14.5%, adjusted mean difference 4.7%). The NI group had higher organ support, medical cost per patient, and longer duration of hospital stay. A decreasing trend in mortality was observed in both the groups (CAI: -0.53%/year and NI: -0.72%/year, P < 0.001).

CONCLUSION

The present analysis of a large Japanese claims database showed that NI is a significant burden on hospitalized patients in aging societies, emphasizing the need to address particularly on NI.

Assessing the impact of transitioning to 11th revision of the International Classification of Diseases (ICD-11) on comorbidity indices

OBJECTIVES

This study aimed to support the implementation of the 11th Revision of the International Classification of Diseases (ICD-11). We used common comorbidity indices as a case study for proactively assessing the impact of transitioning to ICD-11 for mortality and morbidity statistics (ICD-11-MMS) on real-world data analyses.

MATERIALS AND METHODS

Using the MIMIC IV database and a table of mappings between the clinical modification of previous versions of ICD and ICD-11-MMS, we assembled a population whose diagnosis can be represented in ICD-11-MMS. We assessed the impact of ICD version on cross-sectional analyses by comparing the populations' distribution of Charlson and Elixhauser comorbidity indices (CCI, ECI) across different ICD versions, along with the adjustment in comorbidity weighting.

RESULTS

We found that ICD versioning could lead to (1) alterations in the population distribution and (2) changes in the weight that can be assigned to a comorbidity category in a reweighting initiative. In addition, this study allowed the creation of the corresponding ICD-11-MMS codes list for each component of the CCI and the ECI.

DISCUSSION

In common with the implementations of previous versions of ICD, implementation of ICD-11-MMS potentially hinders comparability of comorbidity burden on health outcomes in research and clinical settings.

CONCLUSION

Further research is essential to enhance ICD-11-MMS usability, while mitigating, after identification, its adverse effects on comparability of analyses.

Efficacy of surgical intervention over conservative management in intertrochanteric fractures among nonagenarians and centenarians: a prospective cohort study

BACKGROUND

Optimal treatment strategy for nonagenarians and centenarians with hip fractures (NCHF) remained unknown. The authors aimed to compare the outcomes of surgical and conservative management in NCHF.

METHODS

A prospective cohort study was conducted based on CPMHF database with NCHF patients hospitalized during 2014-2020. Comorbidities were evaluated by mECM score and restricted cubic spline was utilized to visually assess the dose-effect relationship between the mECM and outcomes. Propensity score matching was performed to balance baseline characteristics between nonsurgical and surgical groups. Multivariate logistic regression, Cox proportional hazard analysis, and survival analysis were employed for unfavorable outcomes (UFO) evaluation. Competing risk of death were analyzed based on Fine and Gray's hazard model and then constructed nomogram models for predicting survival rates. Subgroup analyses were used to determine potential population heterogeneity and sensitivity analyses were performed to test robustness of the results.

RESULTS

The authors found increasing trends for UFO with the increase in the mECM score, and that high mECM score (HMS, ≥3) was independently associated with a 2.42-fold (95% CI: 2.07-3.54; P =0.024) increased risk of UFO, which remained significant after considering the competing role of death and were more pronounced in nonsurgical treatment, women, no insurance, and patients with spouse (all P for interaction <0.05). Surgical intervention was identified to be significant protective factors for UFO (RR, 0.59; 95% CI: 0.46-0.75; P <0.001) and severe complications (RR, 0.63; 95% CI: 0.41-0.96; P =0.033) after propensity score matching, as well as survival (HR, 0.40, 95% CI: 0.28-0.58; P <0.001), which remained significant after considering the competing role of death and in all sensitivity analyses and were more pronounced in HMS participants ( P for interaction=0.006). Subgroup analyses revealed surgical patients with HMS had a significantly higher UFO rate (excluding death, P <0.001) while nonsurgical patients with HMS had higher mortality rate as compared to the others ( P =0.005).

CONCLUSION

Surgical treatment for NCHF yields better outcomes compared to conservative treatment.

Human immunodeficiency virus infection is associated with greater risk of pneumonia and readmission after cardiac surgery

Objective

Human immunodeficiency virus infection (HIV+) is associated with a 2-fold increased risk of cardiovascular disease. Increasingly, patients who are HIV + are being evaluated to undergo cardiac surgery. Current risk-adjusted scoring systems, including the Society of Thoracic Surgeons Predicted Risk of Mortality score, fail to stratify HIV + risk. Unfortunately, there exists a paucity of cardiac surgery outcomes data in modern patients who are HIV+.

Methods

We conducted a retrospective review of PearlDiver, an all-payer claims administrative database. In total, 14,714,743 patients were captured between 2010 and 2020. Of these, 59,695 (0.4%) of patients had a history of HIV+, and 1759 (2.95%) of these patients underwent cardiac surgery. Patients who were HIV+ were younger, more often male, and had greater comorbidity, history of hypertension, chronic obstructive pulmonary disease, chronic liver disease, chronic kidney disease, chronic lung disease, and heart failure.

Results

Postoperatively, patients who were HIV + had significantly greater rates of pneumonia (relative risk, 1.70; P = .0003) and 30-day all-cause readmission (relative risk, 1.28, P < .0001). After linear regression analysis, these results remained significant. Data also show that a lesser proportion of patients with HIV + underwent coronary artery bypass grafting, aortic valve replacement, and any cardiac surgery compared with controls.

Conclusions

Patients who are HIV + undergoing cardiac surgery are at greater risk of pneumonia and readmission. Moreover, we discovered lower rates of cardiac surgery in patients who are HIV+, which may reflect limited access to surgery when indicated. Today's risk-adjusted scoring systems in cardiac surgery need to better account for the modern patient who is HIV+.

Development of a comorbidity index for patients undergoing abdominal aortic aneurysm repair

BACKGROUND

Endovascular aneurysm repair (EVAR) and open surgical repair (OSR) are two modalities to treat patients with abdominal aortic aneurysm (AAA). Alternative to individual comorbidity adjustment, a summary comorbidity index is a weighted composite score of all comorbidities that can be used as standard metric to control for comorbidity burden in clinical studies. This study aimed to develop summary comorbidity indices for patients who underwent AAA repair.

METHODS

Patients who went under EVAR or OSR were identified in National Inpatient Sample (NIS) between the last quarter of 2015 to 2020. In each group, patients were randomly sampled into experimental (2/3) and validation (1/3) groups. The weights of Elixhauser comorbidities were determined from a multivariable logistic regression and single comorbidity indices were developed for EVAR and OAR groups, respectively.

RESULTS

There were 34,668 patients underwent EVAR (2.19% mortality) and 4792 underwent OSR (10.98% mortality). Both comorbidity indices had moderate discriminative power (EVAR c-statistic, 0.641; 95% confidence interval [CI], 0.616-0.665; OSR c-statistic, 0.600; 95% CI, 0.563-0.630) and good calibration (EVAR Brier score, 0.021; OSR Brier score, 0.096). The indices had significantly better discriminative power (DeLong P <.001) than the Elixhauser Comorbidity Index (ECI) (EVAR c-statistic, 0.572; 95% CI, 0.546-0.597; OSR c-statistic, 0.502; 95% CI, 0.472-0.533). For internal validation, both indices had similar performance compared with individual comorbidity adjustment (EVAR DeLong P = .650; OSR DeLong P = .431). These indices demonstrated good external validation, exhibiting comparable performance to their respective validation groups (EVAR DeLong P = .891; OSR DeLong P = .757).

CONCLUSIONS

ECI, the comorbidity index formulated for the general population, exhibited suboptimal performance in patients who underwent AAA repair. In response, we developed summary comorbidity indices for both EVAR and OSR for AAA repair, which were internally and externally validated. The EVAR and OSR comorbidity indices outperformed the ECI in discriminating in-hospital mortality rates. They can standardize comorbidity measurement for clinical studies in AAA repair, especially for studies with small samples such as single-institute data sources to facilitate replication and comparison of results across studies.

Assessing the excess costs of the in-hospital adverse events covered by the AHRQ's Patient Safety Indicators in Switzerland

There currently exists no comprehensive and up-to date overview on the financial impact of the different adverse events covered by the Patient Safety Indicators (PSIs) from the Agency for Healthcare Research and Quality. We conducted a retrospective case-control study using propensity score matching on a national administrative data set of 1 million inpatients in Switzerland to compare excess costs associated with 16 different adverse events both individually and on a nationally aggregated level. After matching 8,986 cases with adverse events across the investigated PSIs to 26,931 controls, we used regression analyses to determine the excess costs associated with the adverse events and to control for other cost-related influences. The average excess costs associated with the PSI-related adverse events ranged from CHF 1,211 (PSI 18, obstetric trauma with instrument) to CHF 137,967 (PSI 10, postoperative acute kidney injuries) with an average of CHF 27,409 across all PSIs. In addition, adverse events were associated with 7.8-day longer stays, 2.5 times more early readmissions (within 18 days), and 4.1 times higher mortality rates on average. At a national level, the PSIs were associated with CHF 347 million higher inpatient costs in 2019, which corresponds to about 2.2% of the annual inpatient costs in Switzerland. By comparing the excess costs of different PSIs on a nationally aggregated level, we offer a financial perspective on the implications of in-hospital adverse events and provide recommendations for policymakers regarding specific investments in patient safety to reduce costs and suffering.

Prediction of Venous Thromboembolism in Diverse Populations Using Machine Learning and Structured Electronic Health Records

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity and mortality worldwide. Current risk assessment tools, such as the Caprini and Padua scores and Wells criteria, have limitations in their applicability and accuracy. This study aimed to develop machine learning models using structured electronic health record data to predict diagnosis and 1-year risk of VTE.

METHODS

We trained and validated models on data from 159 001 participants in the Mount Sinai Data Warehouse. We then externally tested them on 401 723 participants in the UK Biobank and 123 039 participants in All of Us. All data sets contain populations of diverse ancestries and clinical histories. We used these data sets to develop small, medium, and large models with increasing features on a range of optimizing portability to maximizing performance. We make trained models publicly available in click-and-run format at https://doi.org/10.17632/tkwzysr4y6.6.

RESULTS

In the holdout and external test sets, respectively, models achieved areas under the receiver operating characteristic curve of 0.80 to 0.83 and 0.72 to 0.82 for VTE diagnosis prediction and 0.76 to 0.78 and 0.64 to 0.69 for 1-year risk prediction, significantly outperforming the Padua score. Models also demonstrated robust performance across different VTE types and patient subsets, including ethnicity, age, and surgical and hospitalization status. Models identified both established and novel clinical features contributing to VTE risk, offering valuable insights into its underlying pathophysiology.

CONCLUSIONS

Machine learning models using structured electronic health record data can significantly improve VTE diagnosis and 1-year risk prediction in diverse populations. Model probability scores exist on a continuum, affecting mortality risk in both healthy individuals and VTE cases. Integrating these models into electronic health record systems to generate real-time predictions may enhance VTE risk assessment, early detection, and preventative measures, ultimately reducing the morbidity and mortality associated with VTE.

Prevalence and risk factors of post-acute sequelae of COVID-19 among United States Veterans

PURPOSE

To better understand Post-Acute Sequelae of COVID-19 (PASC) in the Veteran population, this study aims to determine the prevalence of PASC and identify risk factors associated with its development.

METHODS

This retrospective cohort study included 363,825 Veterans that tested positive for COVID-19 between February 1, 2020, and September 30, 2022. The primary outcome was the development of PASC 30-180 days following an acute infection with SARS-CoV-2. Multivariate logistic regression was utilized to examine factors associated with PASC.

RESULTS

Of the 363,825 Veterans included in the analysis, 164,315 (45%) displayed symptoms of PASC. The Veterans in this analysis were predominantly male, non-Hispanic White, under the age of 65 years old, and lived in an urban residence. The strongest predictors for PASC included Non-Hispanic Black or African American race compared to Non-Hispanic White race (aOR=1.14), being between the ages of 50 and 64 compared to ages 50 and below (aOR=1.80), diabetes (aOR=8.46), and severe acute infection (aOR=1.42).

CONCLUSION

Results demonstrate potential health inequities for vulnerable individuals, as well as increased risk for individuals with pre-existing comorbidities. The prevalence of PASC provides estimates for future health care utilization. The risk factors identified can aid public health interventions to reduce the burden of PASC.

Telehealth Initiation of Buprenorphine for Opioid Use Disorder: Patient Characteristics and Outcomes

BACKGROUND

The COVID-19 pandemic exacerbated access barriers for patients with opioid use disorder. Telehealth presents an opportunity to improve access, treatment quality, and patient outcomes.

OBJECTIVE

To determine patient characteristics associated with initiating buprenorphine treatment via telehealth and to examine how telehealth initiation is associated with access, treatment quality, and health outcomes.

DESIGN AND PARTICIPANTS

This cross-sectional study used deidentified insurance claims to identify opioid use disorder adult patients initiating buprenorphine treatment between March 1, 2020, and November 30, 2021. Multivariable logistic regression assessed determinants of telehealth initiation. Propensity score matching addressed observed differences between in-person and telehealth initiators.

MAIN MEASURES

Treatment quality outcomes included initiation within 14 days of diagnosis, engagement (at least 2 opioid use disorder-related visits), and any buprenorphine refill during the study period. Health outcomes included opioid overdose and opioid use disorder-related emergency department and inpatient visits.

KEY RESULTS

We identified 23,565 adult buprenorphine initiators, including 3314 (14.1%) patients using telehealth. Younger patients (OR 0.91 to 0.77), females (OR 1.18), South (OR 1.63) and Midwest (OR 1.27) regions, rural area (OR 1.12), and higher-income (OR 1.16) neighborhood residents were more likely to use telehealth. Telehealth patients were more likely than in-person patients (54.5% vs. 48.4%; adjusted odds ratio (AOR), 1.29; 95% CI, 1.19-1.40) to stay engaged with opioid use disorder treatment, and more likely to refill buprenorphine during the study period (83.6% vs. 79.0%, AOR 1.37; 95% CI, 1.23-1.52). Telehealth initiation of buprenorphine was associated with 36% lower overdose rate than in-person initiation (adjusted incidence rate ratio 0.64; 95% CI, 0.45-0.94). The two groups evidenced no significant differences in opioid use disorder-related ED visit and hospitalization.

CONCLUSIONS

Our findings suggest that telehealth-initiated buprenorphine treatment is associated with reduced opioid overdose rate and improved patient engagement. Our findings strengthen the case for extending telehealth exemptions and prescribing flexibilities for treatment.

Emergency services utilization by patients with alcohol-associated hepatitis: An analysis of national trends

BACKGROUND

Hospitalization and mortality in patients with alcohol-associated hepatitis (AH), a severe form of liver disease, continue to increase over time. Given the severity of the illness, most hospitalized patients with AH are admitted from the emergency department (ED). However, there are no data on ED utilization by patients with AH. Thus, the Nationwide Emergency Department Sample (NEDS) dataset was analyzed to determine the ED utilization for AH.

METHODS

Temporal trends (2016-2019) and outcomes of ED visits for AH were determined. Primary or secondary AH diagnoses were based on coding priority. Numbers of patients evaluated in the ED, severity of disease, complications of liver disease, and discharge disposition were analyzed. Crude and adjusted rates were examined, and temporal trends evaluated using logistic regression with orthogonal polynomial contrasts for each year.

RESULTS

There were 466,014,370 ED visits during 2016-2019, of which 448,984 (0.096%) were for AH, 85.0% of which required hospitalization. The rate of visits for AH (primary and secondary) between 2016 and 2019 increased from 85 to 106.8/100,000 ED visits. The rate of secondary AH increased more than the rate of primary AH (from 68.6 to 86.5 vs. from 16.4 to 20.3/100,000 ED visits). Patients aged 45-64 years had the highest rate of ED visits for AH, which decreased during the study period, while the rate of ED visits for AH increased in those aged 25-44 years (from 38.5% to 42.9%). The severity of disease (ascites, hepatic encephalopathy, and acute kidney injury) also increased over time. Medicaid and private insurance were the most common payors for patients seeking care in the ED for AH.

CONCLUSIONS

Temporal trends show an overall increase in ED utilization rates for AH, more patients requiring hospitalization, and an increase in the proportion of younger patients presenting to the ED with AH.

The economic burden of cardiac implantable electronic device infections in Alberta, Canada: a population-based study using validated administrative data

BACKGROUND

Cardiac implantable electronic devices (CIED) are being inserted with increasing frequency. Severe surgical site infections (SSI) that occur after device implantation substantially impact patient morbidity and mortality and can result in multiple hospital admissions and repeat surgeries. It is important to understand the costs associated with these infections as well as healthcare utilization. Therefore, we conducted a population-based study in the province of Alberta, Canada to understand the economic burden of these infections.

METHODS

A cohort of adult patients in Alberta who had CIEDs inserted or generators replaced between January 1, 2011 and December 31, 2019 was used. A validated algorithm of International Classification of Diseases (ICD) codes to identify complex (deep/organ space) SSIs that occurred within the subsequent year was applied to the cohort. The overall mean 12-month inpatient and outpatient costs for the infection and non-infection groups were assessed. In order to control for variables that may influence costs, propensity score matching was completed and incremental costs between those with and without infection were calculated. As secondary outcomes, number of outpatient visits, hospitalizations and length of stay were assessed.

RESULTS

There were 26,049 procedures performed during our study period, of which 320 (1.23%) resulted in SSIs. In both unadjusted costs and propensity score matched costs the infection group was associated with increased costs. Overall mean cost was $145,312 in the infection group versus $34,264 in the non-infection group. The incremental difference in those with infection versus those without in the propensity score match was $90,620 (Standard deviation $190,185). Approximately 70% of costs were driven by inpatient hospitalizations. Inpatients hospitalizations, length of stay and outpatient visits were all increased in the infection group.

CONCLUSIONS

CIED infections are associated with increased costs and are a burden to the healthcare system. This highlights a need to recognize increasing SSI rates and implement measures to minimize infection risk. Further studies should endeavor to apply this work to full economic evaluations to better understand and identify cost-effective infection mitigation strategies.

Costs, length of stay and inpatient complications of early surgical decompression after spinal cord injury in a geriatric cohort

Debate regarding timing of surgical decompression after spinal cord injury continues. Recent evidence indicates that early decompression improves neurological outcomes. However, little investigation has been performed regarding how it affects one's hospitalization in a geriatric cohort. 8,999 cases of traumatic SCI who underwent surgical decompression (2002-2011, age 65 + years) within the Nationwide Inpatient Sample were included in univariate and multivariate analyses. Univariate analysis shows that early decompression is more cost effective ($88,564.00 vs $107,849.00, p < 0.0005) and is associated with shorter length of stay (LOS) (8.00 ± 16.15 vs 12.00 ± 15.93 days, p < 0.0005) when compared to late decompression. In multivariate analysis, early decompression continued to be associated with a shorter LOS, though cost was no longer statistically different. Early decompression had less odds of surgical site infection, vasopressor use, decubitus ulcers, but higher odds of cardiac complications, acute renal failure, transfusions and hardware complications. Spinal level of SCI did not affect timing of surgery. Vertebral column fracture did not influence cost or length of stay. In summary, the complex mix of results regarding inpatient complications highlight the innumerable variables and complex decision making that involves surgical treatment of SCI, especially within a susceptible geriatric cohort. However, shorter LOS and lower costs associated with early decompression continue to support its uniform implementation after traumatic SCI.

Comparison of seven comorbidity scores on four-month survival of lung cancer patients

BACKGROUND

The comorbidity burden has a negative impact on lung-cancer survival. Several comorbidity scores have been described and are currently used. The current challenge is to select the comorbidity score that best reflects their impact on survival. Here, we compared seven usable comorbidity scores (Charlson Comorbidity Index, Age adjusted Charlson Comorbidity Index, Charlson Comorbidity Index adapted to lung cancer, National Cancer Institute combined index, National Cancer Institute combined index adapted to lung cancer, Elixhauser score, and Elixhauser adapted to lung cancer) with coded administrative data according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems to select the best prognostic index for predicting four-month survival.

MATERIALS AND METHODS

This cohort included every patient with a diagnosis of lung cancer hospitalized for the first time in the thoracic oncology unit of our institution between 2011 and 2015. The seven scores were calculated and used in a Cox regression method to model their association with four-month survival. Then, parameters to compare the relative goodness-of-fit among different models (Akaike Information Criteria, Bayesian Information Criteria), and discrimination parameters (the C-statistic and Harrell's c-statistic) were calculated. A sensitivity analysis of these parameters was finally performed using a bootstrap method based on 1,000 samples.

RESULTS

In total, 633 patients were included. Male sex, histological type, metastatic status, CCI, CCI-lung, Elixhauser score, and Elixhauser-lung were associated with poorer four-month survival. The Elixhauser score had the lowest AIC and BIC and the highest c-statistic and Harrell's c-statistic. These results were confirmed in the sensitivity analysis, in which these discrimination parameters for the Elixhauser score were significantly different from the other scores.

CONCLUSIONS

Based on this cohort, the Elixhauser score is the best prognostic comorbidity score for predicting four-month survival for hospitalized lung cancer patients.

A novel comorbidity index in Italy based on diseases detected by the surveillance system PASSI and the Global Burden of Diseases disability weights

BACKGROUND

Understanding comorbidity and its burden characteristics is essential for policymakers and healthcare providers to allocate resources accordingly. However, several definitions of comorbidity burden can be found in the literature. The main reason for these differences lies in the available information about the analyzed diseases (i.e., the target population studied), how to define the burden of diseases, and how to aggregate the occurrence of the detected health conditions.

METHODS

In this manuscript, we focus on data from the Italian surveillance system PASSI, proposing an index of comorbidity burden based on the disability weights from the Global Burden of Disease (GBD) project. We then analyzed the co-presence of ten non-communicable diseases, weighting their burden thanks to the GBD disability weights extracted by a multi-step procedure. The first step selects a set of GBD weights for each disease detected in PASSI using text mining. The second step utilizes an additional variable from PASSI (i.e., the perceived health variable) to associate a single disability weight for each disease detected in PASSI. Finally, the disability weights are combined to form the comorbidity burden index using three approaches common in the literature.

RESULTS

The comorbidity index (i.e., combined disability weights) proposed allows an exploration of the magnitude of the comorbidity burden in several Italian sub-populations characterized by different socioeconomic characteristics. Thanks to that, we noted that the level of comorbidity burden is greater in the sub-population characterized by low educational qualifications and economic difficulties than in the rich sub-population characterized by a high level of education. In addition, we found no substantial differences in terms of predictive values of comorbidity burden adopting different approaches in combining the disability weights (i.e., additive, maximum, and multiplicative approaches), making the Italian comorbidity index proposed quite robust and general.

Demographic, social and geographic factors associated with glycaemic control among US Veterans with new onset type 2 diabetes: a retrospective cohort study

OBJECTIVES

This study evaluated whether a range of demographic, social and geographic factors had an influence on glycaemic control longitudinally after an initial diagnosis of diabetes.

DESIGN, SETTING AND PARTICIPANTS

We used the US Veterans Administration Diabetes Risk national cohort to track glycaemic control among patients 20-79-year old with a new diagnosis of type 2 diabetes.

PRIMARY OUTCOME AND METHODS

We modelled associations between glycaemic control at follow-up clinical assessments and geographic factors including neighbourhood race/ethnicity, socioeconomic, land use and food environment measures. We also adjusted for individual demographics, comorbidities, haemoglobin A1c (HbA1c) at diagnosis and duration of follow-up. These factors were analysed within strata of community type: high-density urban, low-density urban, suburban/small town and rural areas.

RESULTS

We analysed 246 079 Veterans who developed a new type 2 diabetes diagnosis in 2008-2018 and had at least 2 years of follow-up data available. Across all community types, we found that lower baseline HbA1c and female sex were strongly associated with a higher likelihood of within-range HbA1c at follow-up. Surprisingly, patients who were older or had more documented comorbidities were more likely to have within-range follow-up HbA1c results. While there was variation by community type, none of the geographic measures analysed consistently demonstrated significant associations with glycaemic control across all community types.

Risk factors and healthcare costs associated with long bone fracture non-union: a retrospective US claims database analysis

BACKGROUND

Few contemporary US-based long bone non-union analyses have recently been published. Our study was designed to provide a current understanding of non-union risks and costs, from the payers' perspective.

METHODS

The Merative™ MarketScan® Commercial Claims and Encounters database was used. Patients with surgically treated long bone (femur, tibia, or humerus) fractures in the inpatient setting, from Q4 2015 to most recent, were identified. Exclusion criteria included polytrauma and amputation at index. The primary outcome was a diagnosis of non-union in the 12 and 24 months post-index. Additional outcomes included concurrent infection, reoperation, and total healthcare costs. Age, gender, comorbidities, fracture characteristics, and severity were identified for all patients. Descriptive analyses were performed. Crude and adjusted rates of non-union (using Poisson regressions with log link) were calculated. Marginal incremental cost of care associated with non-union and infected non-union and reoperation were estimated using a generalized linear model with log link and gamma distribution.

RESULTS

A total of 12,770, 13,504, and 4,805 patients with femoral, tibial, or humeral surgically treated fractures were identified, 74-89% were displaced, and 18-27% were comminuted. Two-year rates of non-union reached 8.5% (8.0%-9.1%), 9.1% (8.6%-9.7%), and 7.2% (6.4%-8.1%) in the femoral, tibial, and humeral fracture cohorts, respectively. Shaft fractures were at increased risk of non-union versus fractures in other sites (risk ratio (RR) in shaft fractures of the femur: 2.36 (1.81-3.04); tibia: 1.95 (1.47-2.57); humerus: 2.02 (1.42-2.87)). Fractures with severe soft tissue trauma (open vs. closed, Gustilo III vs. Gustilo I-II) were also at increased risk for non-union (RR for Gustilo III fracture (vs. closed) for femur: R = 1.96 (1.45-2.58), for tibia: 3.33 (2.85-3.87), RR for open (vs. closed) for humerus: 1.74 (1.30-2.32)). For all fractures, younger patients had a reduced risk of non-union compared to older patients. For tibial fractures, increasing comorbidity (Elixhauser Index 5 or greater) was associated with an increased risk of non-union. The two-year marginal cost of non-union ranged from $33K-$45K. Non-union reoperation added $16K-$34K in incremental costs. Concurrent infection further increased costs by $46K-$86K.

CONCLUSIONS

Non-union affects 7-10% of surgically treated long bone fracture cases. Shaft and complex fractures were at increased risk for non-union.

Open Versus Percutaneous Tracheostomy in Patients With Liver Cirrhosis: Analysis of a Nationwide Database

BACKGROUND

Evidence for the appropriate type of tracheostomy in patients with liver cirrhosis is lacking. A retrospective analysis of the National Inpatient Sample (NIS) was performed.

METHODS

Adult patients with liver cirrhosis undergoing tracheostomy while on mechanical ventilation for respiratory failure were abstracted from the NIS database between 2016 and 2018 and analyzed. Patients were divided according to the type of tracheostomy performed into open tracheostomy (OT) and percutaneous tracheostomy (PT) and analyzed for tracheostomy complications and clinical outcomes. Subgroup analyses were performed for patients with compensated cirrhosis (CC) and decompensated cirrhosis (DC).

RESULTS

A total of 44745 cases were analyzed. The OT group had a higher rate of overall tracheostomy-related complications (TC) (5.1% vs 3.5%; P < .001), hemorrhage from the tracheostomy site (HC) (2.7% vs 1.8%; P = .008) and other complications (OC) (2.7% vs 1.8%, P = .003). Multivariate analyses showed that OT was a risk factor for TC (Adjusted odds ratio (AOR) 1.50, P < .001), HC (AOR 1.46, P = .009), and OC (AOR 1.55, P = .003). Similarly, in subgroup analyses, OT cases, compared to PT, were associated with increased TC (5.0% vs 3.4%, P < .001), HC (2.7% vs 1.7%, P = .002) and OC (2.6% vs 1.8%, P = .020) in DC patients.

DISCUSSION

OT is associated with a significantly higher rate of complications. OT was also associated with more complications in DC patients, suggesting that a percutaneous approach may be the best option in cirrhotic patients when feasible.

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

Background

End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States' utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis.

Methods

TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA.

Results

In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA.With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals ("not-for-profit" and "investor-owned") were significantly more likely to offer TAA over AA.

Conclusion

Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis.

Level of Evidence

Level III, retrospective cohort study.

Does a Community Care programme reach a high health need population and high users of acute care hospital services in Melbourne, Australia? An observational cohort study

OBJECTIVE

The Community Care programme is an initiative aimed at reducing hospitalisations and emergency department (ED) presentations among patients with complex needs. We aimed to describe the characteristics of the programme participants and identify factors associated with enrolment into the programme.

DESIGN

This observational cohort study was conducted using routinely collected data from the National Centre for Healthy Ageing data platform.

SETTING

The study was carried out at Peninsula Health, a health service provider serving a population in Melbourne, Victoria, Australia.

PARTICIPANTS

We included all adults with unplanned ED presentation or hospital admission to Peninsula Health between 1 November 2016 and 31 October 2017, the programme's first operational year.

OUTCOME MEASURES

Community Care programme enrolment was the primary outcome. Participants' demographics, health factors and enrolment influences were analysed using a staged multivariable logistic regression.

RESULTS

We included 47 148 adults, of these, 914 were enrolled in the Community Care programme. Participants were older (median 66 vs 51 years), less likely to have a partner (34% vs 57%) and had more frequent hospitalisations and ED visits. In the multivariable analysis, factors most strongly associated with enrolment included not having a partner (adjusted OR (aOR) 1.83, 95% CI 1.57 to 2.12), increasing age (aOR 1.01, 95% CI 1.01 to 1.02), frequent hospitalisations (aOR 7.32, 95% CI 5.78 to 9.24), frequent ED visits (aOR 2.0, 95% CI 1.37 to 2.85) and having chronic diseases, such as chronic pulmonary disease (aOR 2.48, 95% CI 2.06 to 2.98), obesity (aOR 2.06, 95% CI 1.39 to 2.99) and diabetes mellitus (complicated) (aOR 1.75, 95% CI 1.44 to 2.13). Residing in aged care home and having high socioeconomic status) independently associated with reduced odds of enrolment.

CONCLUSIONS

The Community Care programme targets patients with high-readmission risks under-representation of individuals residing in residential aged care homes warrants further investigation. This study aids service planning and offers valuable feedback to clinicians about programme beneficiaries.

Using Comorbidity Statistical Modeling to Predict Inpatient Mortality: Insights Into the Burden on Hospitalized Patients

Background The expenditures of the United States for healthcare are the highest in the world. Assessment of inpatient disease classifications associated with death can provide useful information for risk stratification, outcome prediction, and comparative analyses to understand the most resource-intensive chronic illnesses. This project aims to adapt a comorbidity index model to the National Inpatient Sample (NIS) database of 2020 to predict one-year mortality for patients admitted with select International Classification of Diseases, 10th Edition (ICD-10) codes of diagnoses. Methodology A retrospective cohort study analyzed mortality with comorbidity using the Charlson comorbidity index model (CCI) in a sample population of an estimated 5,533,477 adult inpatients (individuals aged ≥18 years) obtained from the National Inpatient Database for 2020. A multivariate logistic regression model was constructed with in-hospital mortality as the outcome variable and identifying predictor variables as defined by the Clinical Classifications Software Refined Variables (CCSR) codes for selected ICD-10 diagnoses. Descriptive statistics and the base logistic regression analyses were conducted using SAS statistical software version 9.4 (SAS Institute, Cary, NC, USA). To avoid overpowering, a subsample (n = 100,000) was randomly selected from the original dataset. The initial CCI assigned weights to ICD-10 diagnoses based on the associated risk of death, and conditions with the greatest collective weights were included in a subsequent backward stepwise logistic regression model. Results The results of the base CCI regression analysis revealed 16 chronic conditions with P-values <0.20. Anemia (1,567,081, 28.32%), pulmonary disease (asthma, chronic obstructive pulmonary disease [COPD], pneumoconiosis; 1,210,892, 21.88%), and diabetes without complications (1,077,239, 19.47%) were the three most prevalent conditions associated with inpatient mortality. Results of the backward stepwise regression analysis revealed that severe liver disease/hepatic failure (adjusted odds ratio [aOR] 10.50; 95% confidence interval [CI] 10.40-10.59), acute myocardial infarction (aOR 2.85; 95% CI 2.83-2.87) and malnutrition (aOR 2.15, 95% CI 2.14-2.16) were three most important risk factors and had the highest impact on inpatient mortality (P-value <0.0001). The concordance statistic (c-statistic) or the area under the curve (AUC) for the final model was 0.752. Conclusions The CCI model proved to be a valuable approach in categorizing morbidity classifications associated with the greatest risk of death using a national sample of hospitalized patients in 2020. Study findings provide an objective approach to compare patient populations that bear important implications for healthcare system improvements, clinician treatment approaches, and ultimately decision decision-makers poised to influence advanced models of care and prevention strategies that limit disease progression and improve patient outcomes.

Using machine-learning methods to predict in-hospital mortality through the Elixhauser index: A Medicare data analysis

Accurate in-hospital mortality prediction can reflect the prognosis of patients, help guide allocation of clinical resources, and help clinicians make the right care decisions. There are limitations to using traditional logistic regression models when assessing the model performance of comorbidity measures to predict in-hospital mortality. Meanwhile, the use of novel machine-learning methods is growing rapidly. In 2021, the Agency for Healthcare Research and Quality published new guidelines for using the Present-on-Admission (POA) indicator from the International Classification of Diseases, Tenth Revision, for coding comorbidities to predict in-hospital mortality from the Elixhauser's comorbidity measurement method. We compared the model performance of logistic regression, elastic net model, and artificial neural network (ANN) to predict in-hospital mortality from Elixhauser's measures under the updated POA guidelines. In this retrospective analysis, 1,810,106 adult Medicare inpatient admissions from six US states admitted after September 23, 2017, and discharged before April 11, 2019 were extracted from the Centers for Medicare and Medicaid Services data warehouse. The POA indicator was used to distinguish pre-existing comorbidities from complications that occurred during hospitalization. All models performed well (C-statistics >0.77). Elastic net method generated a parsimonious model, in which there were five fewer comorbidities selected to predict in-hospital mortality with similar predictive power compared to the logistic regression model. ANN had the highest C-statistics compared to the other two models (0.800 vs. 0.791 and 0.791). Elastic net model and AAN can be applied successfully to predict in-hospital mortality.

Comorbidity Patterns and Mortality Among Hospitalized Patients with Psychiatric Disorders and COVID-19

OBJECTIVE

To examine the association between psychiatric and non-psychiatric comorbidity and 28-day mortality among patients with psychiatric disorders and COVID-19.

METHODS

We performed a multicenter observational retrospective cohort study of adult patients with psychiatric disorders hospitalized with laboratory-confirmed COVID-19 at 36 Greater Paris University hospitals (January 2020-May 2021) (N=3,768). First, we searched for different subgroups of patients according to their psychiatric and non-psychiatric comorbidities through cluster analysis. Next, we compared 28-day all-cause mortality rates across the identified clusters, while taking into account sex, age, and the number of medical conditions.

RESULTS

We found 5 clusters of patients with distinct psychiatric and non-psychiatric comorbidity patterns. Twenty-eight-day mortality in the cluster of patients with mood disorders was significantly lower than in other clusters. There were no significant differences in mortality across other clusters.

CONCLUSIONS

All psychiatric and non-psychiatric conditions may be associated with increased mortality in patients with psychiatric disorders and COVID-19. The lower risk of death among patients with mood disorders might be in line with the potential beneficial effect of certain antidepressants in COVID-19, but requires further research. These findings help identify at-risk patients with psychiatric disorders who should benefit from vaccine booster prioritization and other prevention measures.

Clinical and Genetic Characteristics of CKD Patients with High-Risk APOL1 Genotypes

SIGNIFICANCE STATEMENT

APOL1 high-risk genotypes confer a significant risk of kidney disease, but variability in patient outcomes suggests the presence of modifiers of the APOL1 effect. We show that a diverse population of CKD patients with high-risk APOL1 genotypes have an increased lifetime risk of kidney failure and higher eGFR decline rates, with a graded risk among specific high-risk genotypes. CKD patients with high-risk APOL1 genotypes have a lower diagnostic yield for monogenic kidney disease. Exome sequencing revealed enrichment of rare missense variants within the inflammasome pathway modifying the effect of APOL1 risk genotypes, which may explain some clinical heterogeneity.

BACKGROUND

APOL1 genotype has significant effects on kidney disease development and progression that vary among specific causes of kidney disease, suggesting the presence of effect modifiers.

METHODS

We assessed the risk of kidney failure and the eGFR decline rate in patients with CKD carrying high-risk ( N =239) and genetically matched low-risk ( N =1187) APOL1 genotypes. Exome sequencing revealed monogenic kidney diseases. Exome-wide association studies and gene-based and gene set-based collapsing analyses evaluated genetic modifiers of the effect of APOL1 genotype on CKD.

RESULTS

Compared with genetic ancestry-matched patients with CKD with low-risk APOL1 genotypes, those with high-risk APOL1 genotypes had a higher risk of kidney failure (Hazard Ratio [HR]=1.58), a higher decline in eGFR (6.55 versus 3.63 ml/min/1.73 m 2 /yr), and were younger at time of kidney failure (45.1 versus 53.6 years), with the G1/G1 genotype demonstrating the highest risk. The rate for monogenic kidney disorders was lower among patients with CKD with high-risk APOL1 genotypes (2.5%) compared with those with low-risk genotypes (6.7%). Gene set analysis identified an enrichment of rare missense variants in the inflammasome pathway in individuals with high-risk APOL1 genotypes and CKD (odds ratio=1.90).

CONCLUSIONS

In this genetically matched cohort, high-risk APOL1 genotypes were associated with an increased risk of kidney failure and eGFR decline rate, with a graded risk between specific high-risk genotypes and a lower rate of monogenic kidney disease. Rare missense variants in the inflammasome pathway may act as genetic modifiers of APOL1 effect on kidney disease.

Effect of COVID-19 on Acute Ischemic Stroke Severity and Mortality in 2020: Results From the 2020 National Inpatient Sample

BACKGROUND

There is a paucity of nationally representative data regarding the impact of COVID-19 on acute ischemic stroke (AIS) outcome.

METHODS

We created a cross-sectional cohort of nationally weighted National Inpatient Sample nonelective hospital discharges aged ≥18 years with a diagnosis of ischemic stroke from 2016 to 2020. The outcome was in-hospital mortality and exposure was COVID-19 status. To understand the effect of COVID-19 on AIS severity, we report National Institutes of Health Stroke Scale by exposure status. In a final analysis, we used a nationally weighted logistic regression and marginal effects to compare April to December 2020 to the same period in 2019 to understand how the pandemic modified the effect of race and ethnicity and median household income on in-hospital AIS mortality.

RESULTS

We observed significantly higher AIS mortality in 2020 than prior years (2020 versus 2016-19, 7.3% versus 6.3%, P<0.001) and higher National Institutes of Health Stroke Scale in those with COVID-19 than those without (mean: 9.7±9.1 versus 6.6±7.4, P<0.001), but patients with AIS without COVID in 2020 had only marginally higher mortality (2020 versus 2016-2019, 6.6% versus 6.3%, P=0.001). Comparing April to December 2020 to 2019, the adjusted risk of in-hospital AIS mortality was most notably increased in Hispanics (2020 versus 2019: 9.2% versus 5.8%, P<0.001) and the lowest quartile of income (2020 versus 2019: 8.0% versus 6.0%, P<0.001).

CONCLUSIONS

In-hospital stroke mortality increased in 2020 in the United States because of comorbid AIS and COVID-19, which had higher stroke severity. The increase in AIS mortality during April-December 2020 was significantly more pronounced in Hispanics and those in the lowest quartile of household income.

Allostatic load and cardiovascular outcomes in males with prostate cancer

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in men with prostate cancer (PC). Accumulated stress plays an important role in CVD development. The cumulative burden of chronic stress and life events can be measured using allostatic load (AL).

METHODS

The initial cohort included males aged 18 years and older diagnosed with PC (2005-2019). AL was modeled as an ordinal variable (0-11). Fine-Gray competing risk regressions measured the impact of precancer diagnosis AL and postdiagnosis AL in 2-year major cardiac events (MACE). The effect of AL changes over time on MACE development was calculated via piecewise Cox regression (before, and 2 months, 6 months, and 1 year after PC diagnosis).

RESULTS

We included 5261 PC patients of which 6.6% had a 2-year MACE. For every 1-point increase in AL before and within 60 days after PC diagnosis, the risk of MACE increased 25% (adjusted hazard ratio [aHR] =1.25, 95% confidence interval [CI] = 1.18 to 1.33) and 27% (aHR = 1.27, 95% CI = 1.20 to 1.35), respectively. Using AL as a time-varying exposure, the risk of MACE increased 19% (aHR = 1.19, 95% CI = 1.11 to 1.27), 22% (aHR = 1.22, 95% CI = 1.14 to 1.33), 28% (aHR = 1.28, 95% CI = 1.23 to 1.33), and 31% (aHR = 1.31, 95% CI = 1.27 to 1.35) for every 1-point increase in AL before, 2 months after, 6 months after, and 1 year after PC diagnosis, respectively.

CONCLUSION

AL and its changes over time are associated with MACE in PC patients, suggesting a role of a biological measure of stress as a marker of CVD risk among men with PC.

Age-adjusted Charlson comorbidity index predicts postoperative mortality in elderly patients with hip fracture: A prospective cohort

Background

This study aimed to evaluate the clinical association between the age-adjusted Charlson comorbidity index (aCCI) and postoperative mortality in elderly patients.

Materials and methods

Elderly patients with hip fractures were screened from January 2015 to September 2019. After demographic and clinical characteristics were collected, linear and non-linear multivariate Cox regression models were used to identify the association between the aCCI and mortality. All analyses were performed using EmpowerStats and R software.

Results

A total of 2,657 patients were included in the study, and the mean follow-up duration was of 38.97 months. The mean aCCI score was 4.24 ± 1.09, and 977 (34.14%) died of all-cause mortality. The fully-adjusted linear multivariate Cox regression models showed the aCCI to be associated with mortality [hazard ratio (HR) = 1.31, 95% confidence interval (CI):1.21-1.41, P < 0.0001]. Patients in Q2 showed greater mortality (HR = 1.60, 95% CI: 1.23-2.09; P = 0.0005) than those in Q1; patients in Q3 showed greater mortality (HR = 2.18, 95% CI: 1.66-2.87; P < 0.001) than those in Q1. In addition, the P-value for the trend also showed a linear association in the three models (P < 0.0001). In the sensitivity analysis, propensity score matching was used, and the results were stable.

Conclusion

The mortality risk of hip fractures increased by 31% when the aCCI increased by one unit. aCCI score was shown to be a good predictor of three-year mortality following hip fracture.

Clinical trial registration

http://www.chictr.org.cn/showproj.aspx?proj=152919, identifier ChiCTR2200057323.