P6381Cardiac arrest patients presenting to hospitals at weekends are not subject to the weekend effect: insights from ACALM big data, United Kingdom

Introduction

Patients presenting to hospital with a cardiac arrest are associated with significant mortality in the United Kingdom. The evidence for the weekend affect involving cardiac arrests is unclear and we investigated this further with ACALM big data.

Methods

Anonymous information on patients presenting to hospital with a cardiac arrest was obtained from several hospitals in UK between 2000–2014. ICD-10 and OPCS-4 codes were used to trace patients coded for primary cardiac arrest, co-morbidities and mortality data.

Results

Details of 4803 patients presenting with cardiac arrest is shown in Table1. Cox regression model including age, gender, ethnic group, Charlson score and the top ten causes of death in the UK showed that weekend presentation did not contribute to increased mortality (OR 1.01; 95%C.I 0.94–1.11; p=0.692)

Table 1. Demographics and co-morbidities of cardiac arrest patients presenting on weekdays and weekends Weekday Weekend N (%) 3892 (81.0) 919 (19.0) Mean age ± S.D (years) 67.7±16.6 67.4±17.5 Male, % 55.4 54.1 Co-morbidities   Mean Charlson Index 1.52 1.33   Heart Failure % 21.4 20.4   IHD % 38.4 37.1   Cancer (Lung, Breast or Colon) % 5.2 3.8   Cerebrovascular Disease % 6.4 6.3   COPD % 15.0 12.0   CKD % 9.4 7.7   Dementia % 4.7 2.6   Pneumonia % 14.7 14.4 Outcomes   Crude 30 day mortality % 25.4* 32.8*   Crude 1 year mortality % 41.0* 44.3* *Cox regression analyses showed no significant differences in mortality between weekend and weekday presentation.

Conclusion

We have demonstrated that the “weekend effect” is not present in patients admitted to hospital with cardiac arrest. Our findings can perhaps be explained by the presence of 24/7 cardiac arrest teams present in acute hospitals.

Abstract P4-16-05: Avoidable acute care use associated with nausea and emesis among patients receiving AC, carboplatin, or cisplatin for breast cancer

Background: In order to improve care and reduce costs of cancer treatment, attention has focused on reducing inpatient (IP) and emergency room (ED) utilization. The US Centers for Medicare and Medicaid Services (CMS) recently implemented an oncology outcome measure (OP-35) to assess the quality of care and determine outpatient hospital payment. It assesses 30-day post-chemotherapy rates of IP or ED events deemed “potentially avoidable” by CMS due to association with any of 10 CMS-defined toxicities: anemia, dehydration, diarrhea, fever, nausea, emesis, neutropenia, pain, pneumonia, or sepsis. Although CMS found that 20% of chemotherapy treatment resulted in such events, event rates with highly emetogenic chemotherapy (HEC) are understudied, particularly for breast cancer (bCA) patients treated with anthracycline + cyclophosphamide (AC), carboplatin, or cisplatin.

Methods: In a large electronic health record database focused on US integrated delivery networks, HEC courses of therapy were identified from 4Q 2012 to 3Q 2017. IP/ED events within 30 days of chemotherapy administration were considered related to the OP-35 measure if they included a diagnosis code of any of the ten OP-35 toxicities, per CMS' definitions. HEC chemotherapy use, IP/ED events, bCA diagnosis, and toxicities were identified by ICD-9, ICD-10, and procedural codes. Subgroups were evaluated for 3 common HECs: AC, carboplatin (>14 days apart, as a proxy for AUC ≥4), and cisplatin.

Results: 4128 courses of HEC in bCA were identified. Of these, 2304 involved AC (median 4 cycles), 1721 involved carboplatin (median 6 cycles), and 103 involved cisplatin (median 4 cycles), with median ages of 55, 59, and 64, respectively. 30-day IP/ED events were seen in 25% of these HEC bCA courses (22%, 30% and 23% for AC, carboplatin, and cisplatin, respectively). The 10 CMS-defined toxicities were associated with an IP/ED event for 73%, 72%, and 76% of events for these AC, carboplatin, and cisplatin courses respectively, confirming that these are principal contributors to 30-day IP/ED use for patients receiving HEC in bCA. The top five that were most commonly associated with IP/ED for bCA for patients receiving AC, carboplatin, or cisplatin were pain 53%/49%/63%, anemia 51%/51%/38%, fever 48%/31%/38%, neutropenia 46%/27%/31%, and nausea/emesis 30%/40%/25%; patients may have had ≥1 toxicity associated with each IP/ED event. The IP/ED rate may be understated because some events, particularly ED, may occur out of the network the EHR data covers.

Conclusion: One quarter of patients receiving AC, carboplatin, or cisplatin for bCA visit the ED or are hospitalized within 30 days of at least one of their chemotherapy administrations. Most events involved ≥1 of 10 toxicities deemed avoidable causes of hospitalization by CMS and now tracked as an oncology outcome measure. Relative to patients receiving AC, acute care rates for patients receiving carboplatin were lower for fever and neutropenia and higher for nausea/emesis, perhaps because the study period largely precedes the 2017 addition of carboplatin AUC ≥4 to national guidelines as HEC requiring triplet antiemetic prophylaxis. Toxicity prevention and symptom monitoring are crucial to reduce acute care needs.

Citation Format: Ruddy KJ, Roeland EJ, LeBlanc TW, Binder G, Sebastiani S, Potluri R, Schmerold LM, Papademetriou E, Navari RM. Avoidable acute care use associated with nausea and emesis among patients receiving AC, carboplatin, or cisplatin for breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-05.

Risk factors for mortality in Down syndrome

BACKGROUND

Down syndrome is a genetic condition that contributes to a significantly shorter life expectancy compared with the general population. We investigated the most common comorbidities in a population of acute hospital patients with Down syndrome and further explored what the most common risk factors for mortality are within this population.

METHOD

From our database of one million patients admitted to National Health Service (NHS) Trusts in northern England, we identified 558 people who had Down syndrome. We compared this group with an age- and gender-matched control group of 5580 people.

RESULTS

The most prevalent comorbid diseases within the Down's population were hypothyroidism (22.9%) and epilepsy (20.3%). However, the conditions that had the highest relative risks (RRs) in the Down's population were septal defects and dementia. Respiratory failure, dementia and pneumonia were the most significantly related comorbidities to mortality in the Down syndrome population. In the control population, respiratory failure, dementia and renal failure were the most significant disease contributors. When these contributors were analysed using multivariate analysis, heart failure, respiratory failure, pneumonia and epilepsy were the identified risk factors for in-hospital mortality in the Down syndrome population. Respiratory failure was the sole risk factor for mortality in the Down syndrome population [RR = 9.791 (1.6-59.9) P ≤ 0.05], when compared with the risk factors for mortality in the control population.

CONCLUSIONS

There is significant medical morbidity in Down syndrome. This morbidity contributes to the lower life expectancy. Respiratory failure is a risk factor for mortality in Down syndrome. We need to thoroughly investigate people with Down syndrome to ensure any treatable illnesses are well managed.

Assessment of tuberculosis burden in China using a dynamic disease simulation model

SETTING

Although a preventable and treatable disease, tuberculosis (TB) is among the top 10 causes of death worldwide. A consequence of inadequately treated drug-susceptible TB (DS-TB) is multidrug-resistant TB (MDR-TB).

OBJECTIVES

To improve our understanding of the primary drivers of incidence and prevalence of DS- and MDR-TB in China.

METHODS

The Tuberculosis Disease Transmission Model (TBDTM) uses historical and current disease epidemiology and transmission trends and treatment effectiveness, and accounts for annual changes to these to estimate future DS-TB and MDR-TB burden.

RESULTS

The model shows that in China, by 2050, incidence, prevalence and mortality of DS-TB will decrease by 32%, 50% and 41%, respectively, whereas MDR-TB will increase by respectively 60%, 48% and 35%. Reduction in DS-TB is a result of high treatment and cure rates leading to a decrease in the prevalence of latent tuberculous infection (LTBI), while the increase in MDR-TB is attributed to inappropriate treatment, leading to high transmission of infection and increased LTBI prevalence.

CONCLUSIONS

These results demonstrate a reduction in DS-TB in China over the next 40 years, while MDR-TB will increase. Improvements in the diagnosis and treatment of MDR-TB are needed to counter this threat. The TBDTM tool has potential value in public health practice by demonstrating the impact of interventions and estimating their cost-effectiveness.

Alzheimer's disease and co-morbidity: increased prevalence and possible risk factors of excess mortality in a naturalistic 7-year follow-up

BACKGROUND

Subjects with late-onset Alzheimer's disease (AD) have to be sufficiently healthy to live long enough to experience and to be diagnosed with dementia in later life. In contrast, neurodegeneration and cognitive deficits in AD may increase the frequency of co-morbid disorders and their possible influence on mortality. Consequently, we investigated whether the pattern of co-morbidity and its relevance for later death differed between hospitalized AD and age-matched controls subjects.

METHODS

Co-morbid diseases with a prevalence of more than 1% at hospital admission were compared between 634 hospitalized AD and 72,244 control subjects aged above 70 years admitted to the University of Birmingham NHS Trust between 1 January 2000 to 31 December 2007. Risk factors, i.e. co-morbid diseases that were predictors of mortality within the 7-year follow-up, were identified and compared.

RESULTS

Subjects with AD suffer more eating disorders, infections, brain diseases and neck of femur fractures than other hospitalized elderly patients. In contrast, some cardiovascular diseases and diabetes mellitus were less prevalent in AD subjects in comparison with hospitalized controls. Diseases that might have contributed to later mortality in AD were pneumonia, ischemic heart disease and gastroenteritis, but there were no significant differences in their impact on mortality compared to other hospitalized elderly subjects with the same co-morbidities in multivariate logistic regression analyses.

CONCLUSION

Patients with AD have a different pattern of co-morbidity, but die from the same diseases as other hospitalized patients. Infections including pneumonia and diseases that may occur secondary to neurodegeneration and cognitive decline may need special attention in patients with AD who may not be able to identify or report the early symptoms. Preventive measures may be helpful to reduce the high risk and fatal consequences of undetected disease in AD.

Apolipoprotein E allele 4 is not a sufficient or a necessary predictor of the development of Mild Cognitive Impairment

The presence of Mild Cognitive Impairment (MCI) and of an apolipoprotein E (apoE) varepsilon4 allele both predict the development of Alzheimer's disease. However, the extent to which this allele also predicts the development of MCI is unclear even though MCI is an early transitional stage in the development of Alzheimer's disease. The present study investigates the prevalence of the apoE varepsilon4 allele in incipient MCI. Participants were recruited from the population-based Leipzig Longitudinal Study of the Aged (LEILA75+). All subjects who were initially cognitively healthy, i.e. did not meet MCI criteria described by Petersen [Petersen RC. Mild cognitive impairment. J Intern Med 2004; 256(3): 183-94], and whose apoE status could be determined were followed-up. After 4.5 years, 15.5% of the cognitively healthy target population had developed MCI. The frequencies of the apoE varepsilon4 genotype did not differ between individuals with incipient MCI (12.9%) and individuals who remained cognitively healthy during the study (18.4%, p>0.5). Consequently, the apoE varepsilon4 genotype is not a necessary or sufficient risk factor for MCI. Further studies need to investigate the influence of the whole range of genetic and environmental risk factors on the course of Alzheimer's disease including the initial development of MCI and the later conversion to Alzheimer's disease.

Increased 5-year mortality in the migrant South Asian stroke patients with diabetes mellitus in the United Kingdom: the West Birmingham Stroke Project

BACKGROUND

Stroke is a major cause of premature mortality in Britain, but its burden is markedly greater amongst South Asians. Because of the paucity of data in this area, we investigated the magnitude and impact of risk from cardiovascular comorbidities on survival amongst South Asian stroke patients.

METHODS

We reviewed hospital case records of consecutive first in life time ischaemic stroke patients [self reported ethnicity and International Classification of Disease (ICD) 10th revision, codes 430-438] admitted to an inner city hospital in the UK between 1997 and 2001. In-hospital mortality data and CVD risk factors were analysed. Five-year mortality data was obtained from the National Health Tracing Services.

RESULTS

Of 1474 ischaemic stroke patients, 242 (16%) were South Asian of whom, 143 (59.1%) were male. The prevalence of hypertension was 70.2%, followed by diabetes 56.2%, hyperlipidaemia 7% and myocardial infarction 10.3%. At 5 years follow-up, 40.5% had died. Cumulative event-free survival at 5 years was significantly poorer in patients with diabetes (log-rank test, p=0.009). On Cox regression analysis, incorporating age, gender and other CVD risk factors, diabetes mellitus was an independent predictor of mortality odds ratio=1.65 (1.02-2.6, p=0.039). Hypertension and dyslipidaemia did not discriminate survival amongst South Asian patients.

CONCLUSION

Stroke mortality in South Asians is associated with presence of diabetes mellitus. This highlights the significance of early and intensive CVD risk modification strategies in ethnic minorities particularly in patients with diabetes. Further research is warranted in South Asians to examine the underlying basis and related pathophysiological abnormalities.

Secular trends in the cardiovascular risk profile and mortality of stroke admissions in an inner city, multiethnic population in the United Kingdom (1997–2005)

Our objective was to study ethnic differences in the cardiovascular risk profile and mortality of stroke admissions to an inner city teaching hospital serving a multiethnic population in Birmingham, UK, over a 9-year period (1997-2005). Hospital case notes and registry data of 3083 patients admitted with a first onset stroke were reviewed. Secular trends in the prevalence of risk factors (hypertension, diabetes, hyperlipidaemia, atrial fibrillation and myocardial infarction), hospital admission rates and 30-day mortality among Afro-Caribbean, European Caucasian and South Asian ethnic groups were analysed. Between 1997 and 2005, there were 3083 first onset strokes, of whom 47.6% (1595) were men, 9.3% Afro-Caribbean, 57.8% European Caucasian and 15.1% South Asian. There was a significant trend towards a reduction in non-haemorrhagic stroke admissions over the study period (P<0.001), with no ethnic variation (P=0.07). Increases in hypertension and hyperlipidaemia were observed (P<0.001), whereas myocardial infarction showed a decline (P<0.001). Compared to other ethnic groups, South Asian patients were younger on admission (P<0.001), had more hyperlipidaemia (P<0.05) and poorer survival at 30 days (P=002). We conclude that cardiovascular risk profiles among patients admitted with non-haemorrhagic stroke have changed over the last decade. In particular, hyperlipidaemia has increased, especially among South Asians. The reduced decline in stroke admissions and 30-day survival of stroke in South Asians in recent years warrants further investigation and highlights the importance of a targeted health-care approach in the migrant ethnic minorities.