Lack of gender and racial differences in surgery and mortality in hospitalized Medicare beneficiaries with bleeding peptic ulcer

A Cross-Sectional Retrospective Analysis of the Racial and Geographic Variations in Cataract Surgery

BACKGROUND

Cataract surgery is the most common surgery performed on beneficiaries of Medicare, accounting for more than $3.4 billion in annual expenditures. The purpose of this study is to examine racial and geographic variations in cataract surgery rates and determine the association between the racial composition of the community population and the racial disparity in the likelihood of receiving necessary cataract surgery.

METHODS

Using the national prevalence rates from the National Institute of Eye Health and the 2010 Healthcare Cost and Utilization Project-Florida State Ambulatory Surgery Database, we determined the estimated cases of cataract and the actual number of cataract procedures performed, on four race/gender determined groups aged 65 and over in the state of Florida in 2010. The utilization rates and disparity ratios were also calculated for each Florida county. The counties were segmented into groups based on their racial composition. The association between racial composition and disparity ratios in receiving necessary cataract surgery was examined. The Geographic Information System was used to display county-level geospatial relationships.

RESULTS

African-Americans have a lower gender-specific cataract prevalence (African-American male = 0.246, African-American female = 0.392, white male = 0.368, and white female = 0.457), but they are also less likely than whites to receive necessary cataract surgery (utilization rate: African-American male = 7.92%, African-American female = 6.17%, white male = 12.08%, and white female = 10.54%). The statistical results show no overall differences between the disparity ratios and the racial composition of the communities. However, our geospatial analyses revealed a concentration of high racial disparity/high white population counties largely along the West Coast and South Central portion of the state.

CONCLUSIONS

There are racial differences in the likelihood of receiving necessary cataract surgery. However, there is no significant statewide association between the racial composition of the community population and the racial disparity in the likelihood of receiving necessary cataract surgery. Geospatial techniques did, however, identify subpopulations of interest which were not otherwise identifiable with typical statistical approaches, nor consistent with their conclusions.

Opposing effects of aspirin and anticoagulants on morbidity and mortality in patients with upper gastrointestinal bleeding

OBJECTIVE

We aimed to determine the effect of antithrombotics on in-hospital mortality and morbidity in patients with peptic ulcer disease-related upper gastrointestinal bleeding (PUD-related UGIB).

METHODS

The study cohort was retrospectively selected from a tertiary center database of patients with PUD-related UGIB, defined as bleeding due to gastric or duodenal ulcers, or erosive duodenitis, gastritis or esophagitis. Outcomes were compared among patient groups based on their antithrombotic medications before admission. Patients on no antithrombotics served as controls. The composite adverse outcomes, in-hospital mortality, rebleeding and/or need for surgery were measured. Severe bleeding and in-hospital complications were also recorded.

RESULTS

Of 398 patients with PUD-related UGIB, 44.5% were on aspirin or anticoagulants only. The composite adverse outcome was most common in patients taking anticoagulants only (40.5%), intermediate in controls (23.1%) and least in those taking aspirin only (12.1%). On multivariate analysis, patients taking aspirin alone had a significantly lower risk of adverse outcome events (odds ratio [OR] 0.4, 95% CI 0.2-0.8) and a shorter length of hospital stay (regression coefficient = -3.4, 95% CI [-6.6, -0.6]). In contrast, taking anticoagulants was associated with a greater risk of adverse outcome events (OR 2.3, 95% CI 1.0-5.3), severe bleeding (OR 2.6, 95% CI 1.2-5.8) and in-hospital complications (OR 2.9, 95% CI 1.3-6.6).

CONCLUSIONS

Patients with PUB-related UGIB while taking aspirin had fewer adverse outcomes compared with those taking anticoagulants. Aspirin may have beneficial effects in this population.

Decreasing trend of upper gastrointestinal bleeding mortality risk over three decades

BACKGROUND

Upper gastrointestinal bleeding (UGIB) causes over $1 billion in medical expenses annually.

AIMS

The purpose of this study was to examine changes of UGIB mortality risks and trends over the last three decades.

METHODS

We analyzed the National Hospital Discharge Sample from 1979 to 2009. Patients with primary ICD-9 code representing a diagnosis of UGIB were included. The UGIB mortality risks and trends in each decade by anatomical sites, bleeding causes, comorbidities, and other important variables were analyzed.

RESULTS

UGIB mortality risk decreased by 35.4 % from 4.8 % in the first decade to 3.1 % in the third decade (P < 0.001). Age and number of hospitalization days were significant risk factors in all decades. Most significant decreases were observed in patients over 65 years and during the first day of admission. Gastric (P < 0.001) and esophageal (P = 0.018) bleedings showed significant decreasing mortality risk trends. Duodenal bleeding mortality risk was stable in three decades. Mortality risk declined significantly among patients with renal failure (from 50.0 to 4.0 %) and heart failure (from 17.9 to 5.2 %; both P < 0.001) while changes in cases with ischemic heart disease, cancer, and liver failure were less significant.

CONCLUSION

UGIB morality risks, especially of the first hospital day and geriatric patients, significantly decreased over the last three decades, presumably from recent advances in emergency medical care. Mortality risk of gastric, but not duodenal, bleeding had the most significant reduction. Critical care improvements in patients with various comorbidities may explain significant UGIB mortality risk reductions. This study provides invaluable insight into the causes and trends of UGIB mortality risks for future studies.

The risk of peptic ulcer bleeding mortality in relation to hospital admission on holidays: a cohort study on 8,222 cases of peptic ulcer bleeding

OBJECTIVES

Urgent endoscopic intervention is important in the management of patients with peptic ulcer bleeding (PUB). Hospital admission on Sundays or on public holidays may be associated with an increased mortality. This study sets to investigate whether mortality among patients with PUB differs between holiday and weekday admissions, and also to investigate the association between mortality and the waiting time for endoscopy.

METHODS

Patients with PUB admitted to the Prince of Wales Hospital from 1993 to 2005 were prospectively recruited in the data set. Mortality and cause of death were documented. Predicting variables included patient characteristics, waiting time for endoscopy, and holiday or weekday admissions. Bivariate analyses and multivariate logistic regression models were used to evaluate risk factors on 30-day mortality after endoscopy.

RESULTS

A total of 8,222 patients with PUB were enrolled among which 1,573 (19.1%) were admitted on holidays. A total of 334 (4.1%) patients died within 30 days after hospital admission. There was no significant difference in mortality rate between holiday and weekday admissions (4.1 vs. 4.0%, P=0.876). Using logistic regression adjusted for age, hemodynamic shock, ulcer history, and severe comorbid illness, the waiting time for endoscopy was correlated with the risk of 30-day mortality (odds ratio (OR), 95% confidence interval (95% CI)=1.10, 1.06-1.14). Holiday admission has not increased the mortality risk (OR, 95% CI=1.07, 0.80-1.43).

CONCLUSIONS

When therapeutic endoscopy can be offered within 1 day after admission for PUB, holiday admission will not adversely affect bleeding mortality.

Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases

OBJECTIVES

Despite advances in endoscopic and pharmacological treatment for peptic ulcer bleeding (PUB), mortality remains at 5-10% worldwide. Our aim was to investigate the causes of death in a prospective cohort of PUB in a tertiary referral center.

METHODS

Between 1993 and 2005, all patients with upper gastrointestinal bleeding (UGIB) admitted to the Prince of Wales Hospital were prospectively registered. Demographic data, characteristics of ulcer, and pharmacological, endoscopic, and surgical therapy, were documented. Mortality cases were classified as (A) bleeding-related death (A1: uncontrolled bleeding, A2: within 48 h after endoscopy, A3: during surgery for uncontrolled bleeding, A4: surgical complications or within 1 month after surgery, and A5: endoscopic related mortality) or (B) non-bleeding-related death (B1: cardiac causes, B2: pulmonary causes, B3: cerebrovascular disease, B4: multiorgan failure, and B5: terminal malignancy).

RESULTS

In all, 18,508 cases of UGIB were enrolled; among them, 10,428 cases from 9,375 patients were confirmed to have PUB, and 577 (6.2%) patients died. There were significantly more patients who died of non-ulcer bleeding causes (79.7%) than bleeding causes (18.4%). The mean (s.d.) age of those who died of bleeding-related causes was higher (75.4 (12.6) years) than that of those who died of non-bleeding causes (71.7 (13.1) years) (P=0.010). Most bleeding-related deaths occurred when immediate control of bleeding failed (29.2%) or when patients died within 48 h after endoscopic therapy (25.5%). Among those who died of non-bleeding-related causes, multiorgan failure (23.9%), pulmonary conditions (23.5%), and terminal malignancy (33.7%) were most common.

CONCLUSIONS

The majority of PUB patients died of non-bleeding-related causes. Optimization of management should aim at reducing the risk of multiorgan failure and cardiopulmonary death instead of focusing merely on successful hemostasis.

Use and impact of early endoscopy in elderly patients with peptic ulcer hemorrhage: a population-based analysis

BACKGROUND

Upper endoscopy performed within 1 day of presentation, or early endoscopy, has been proposed as an intervention to improve the efficiency and outcomes of care for patients with peptic ulcer hemorrhage. However, the use and outcomes have not been studied in a national, U.S.-based sample.

OBJECTIVE

To determine the prevalence and associated outcomes of early versus delayed endoscopy in bleeding peptic ulcers.

DESIGN

Using a 5% random sample of inpatient and outpatient Medicare claims from 2004 in patients aged 66 years and older (mean [standard deviation] age 78.4 +/- 7.7 years), we identified 2592 patients, all of whom underwent endoscopy.

MAIN OUTCOME MEASUREMENTS

Univariate and multivariate models were used to determine factors associated with 30-day mortality, upper GI surgery, and length of hospital stay.

RESULTS

Early endoscopy was performed in 1854 patients (71.5%) and was somewhat more common with outpatient management. Early endoscopy was independently associated with a significant decrease in the length of hospital stay (-1.95 days, 95% CI, -2.60 to -1.29 days) as well as a lower likelihood of surgery (odds ratio, 0.37; 95% CI, 0.21-0.66). Early endoscopy was not associated with 30-day mortality in either univariate or multivariate analyses.

LIMITATIONS

Use of claims data lacking clinical detail and restriction to the Medicare-age population.

CONCLUSIONS

In this population-based study of older patients with peptic ulcer hemorrhage, early endoscopy was associated with increased efficiency of care, lower rates of surgery, and potentially improved control of hemorrhage. Thus, unless specific contraindications exist, the data support the routine use of early endoscopy.

Outpatient management of nonvariceal upper gastrointestinal hemorrhage: unexpected mortality in Medicare beneficiaries

BACKGROUND & AIMS

Outpatient management of selected patients with nonvariceal upper gastrointestinal hemorrhage (UGIH) has been proposed as a mechanism to decrease resource utilization and expenditures. However, the true prevalence and outcomes of this practice have not been well evaluated in population-based studies.

METHODS

We identified a cohort of 9123 episodes of UGIH in 2004 Medicare claims data, including 3506 (38.4%) managed as outpatients. Clinical characteristics, treatment, and outcomes were compared between inpatient and outpatient groups. In order to adjust for potential selection bias in outpatient treatment, propensity score analysis was used to divide patients into quartiles of likelihood for inpatient treatment.

RESULTS

Inpatients tended to be older, with higher comorbidity scores, and were more likely to have a bleeding ulcer or tear. Inpatients were also more likely to undergo endoscopy, including early endoscopy and therapeutics, and require surgery. The overall 30-day mortality rate was 8.0% in the inpatient group and 6.3% in the outpatient group (P< .001), and in the quartile of patients most likely to be managed as inpatients, the 30-day mortality rate was higher in outpatients than in inpatients.

CONCLUSIONS

The prevalence of outpatient management of UGIH in the Medicare population was almost 40%, and although patients were likely selected for outpatient management based on clinical criteria, the overall mortality rate in outpatients was considerable. Any potential financial benefit should be balanced against significant mortality rates, at least some of which could possibly be avoided with hospitalization. More optimal selection of candidates for outpatient therapy is likely needed.

Does gender influence emergency department management and outcomes in geriatric abdominal pain?

Prior studies have suggested gender-based differences in the care of elderly patients with acute medical conditions such as myocardial infarction and stroke, but it is unknown whether these differences are seen in the care of abdominal pain. The objective of this study was to examine differences in evaluation, management, and diagnoses between elderly men and women presenting to the Emergency Department (ED) with abdominal pain. For this observational cohort study, a chart review was conducted of consecutive patients aged 70 years or older presenting with a chief complaint of abdominal pain. Primary outcomes were care processes (e.g., receipt of pain medications, imaging) and clinical outcomes (e.g., hospitalization, etiology of pain, and mortality). Of 131 patients evaluated, 60% were women. Groups were similar in age, ethnicity, insurance status, and predicted mortality. Men and women did not differ in the frequency of medical (56% vs. 57%, respectively), surgical (25% vs. 18%, respectively), or non-specific abdominal pain (19% vs. 25%, respectively, p = 0.52) diagnoses. Similar proportions underwent abdominal imaging (62% vs. 68%, respectively, p = 0.42), received antibiotics (29% vs. 30%, respectively, p = 0.85), and opiates for pain (35% vs. 41%, respectively, p = 0.50). Men had a higher rate of death within 3 months of the visit (19% vs. 1%, respectively, p < 0.001). Unlike prior research in younger patients with abdominal pain and among elders with other acute conditions, we noted no difference in management and diagnoses between older men and women who presented with abdominal pain. Despite a similar predicted mortality and ED evaluation, men had a higher rate of death within 3 months.

The inaccuracy of ICD-9-CM Code 530.2 for identifying patients with Barrett's esophagus

Barrett's esophagus (BE) is a chronic complication associated with gastroesophageal reflux disease. The ICD-9-CM code used for BE, 530.2, is also used for patients with 'ulcer of the esophagus.' We aimed to determine if the ICD-9-CM code of 530.2 is reliable for identifying cases of Barrett's esophagus within databases for research purposes. We reviewed the records of all patients assigned code 530.2 at two university medical center hospitals and a veterans' administration hospital over a cumulative 16-year period. Billing records provided information about where the code was assigned, whether it was a major or minor diagnosis, and if the code was assigned on multiple occasions for each patient. Histology and endoscopy records were reviewed to confirm the diagnosis of Barrett's esophagus. Among 435 patients with code 530.2 in their records, 354 (82%) had an esophageal biopsy reported and 393 (90%) had an endoscopy report available for review. Only 182 (42%) had specialized intestinal metaplasia documented in a biopsy from an area of salmon-colored mucosa arising above the esophagogastric junction (51% of those with histology available). There were 288 patients (66%) with an endoscopic diagnosis of Barrett's esophagus (73% of those with an endoscopy reported). Variables associated with documented specialized intestinal metaplasia were age > or = 60 (OR 2.3; 95% CI 1.4-3.7), multiple assignments of 530.2 (OR 3.2; 95% CI 2.0-5.0), and assignment of 530.2 in a gastrointestinal (GI) clinic or an endoscopy unit (OR 3.5; 95% CI 2.0-6.3). The positive predictive value of the code being assigned in a GI location was 48% (95% CI 43-54%). Therefore, ICD-9-CM code of 530.2 is not specific for the diagnosis of Barrett's esophagus. The usage of code 530.2 in a GI setting was not sufficiently predictive of BE to be reliable for rigorous epidemiological studies.

Hospital characteristics and racial disparities in hospital mortality from common medical conditions

OBJECTIVES

Less is known about racial disparities in mortality from medical conditions than for procedures. We determined whether black-white disparities in risk-adjusted hospital mortality exist for five common conditions (myocardial infarction, congestive heart failure, cerebral vascular accident, gastrointestinal hemorrhage and pneumonia), and to determine the role of hospital characteristics.

METHODS

We used the 2003 Nationwide Inpatient Sample. Where a mortality disadvantage for black patients was demonstrated, additional analyses assessed whether the degree of disparity varied by hospital characteristics.

RESULTS

Mortality for black patients was equivalent to or lower than that for white patients for four of the five conditions. Black patients were more likely than white patients to die from gastrointestinal hemorrhage (1.5% vs. 1.1%, p<0.001). In multivariate analysis, hospital racial composition was the only characteristic associated with degree of disparity for gastrointestinal hemorrhage, with hospitals discharging fewer black patients demonstrating greater disparity.

CONCLUSIONS

In a large, multistate sample, there was no evidence of disparities in mortality for four of five common conditions. Black-white racial disparities in mortality from gastrointestinal hemorrhage, however, may be associated with hospital racial composition.

Effects of alcohol-related disease on hip fracture and mortality: a retrospective cohort study of hospitalized Medicare beneficiaries

OBJECTIVES

This study investigated the effect of alcohol-related disease on hip fracture and mortality.

METHODS

A retrospective cohort design was used. The study cohort consisted of hospitalized Medicare beneficiaries with alcohol-related disease (n = 150,119) and randomly matched controls without alcohol-related disease (n = 726,218) identified through the 1988-1989 inpatient claims file. Incidence rates of hip fracture and mortality were examined.

RESULTS

During the study period, 20,620 patients developed hip fracture, with 6973 cases among patients with alcohol-related disease and 13,647 cases among patients without alcohol-related disease. After adjustment for potential confounders, patients with alcohol-related disease had a 2.6-fold increased risk of hip fracture relative to patients without alcohol-related disease (95% confidence interval = 2.5, 2.6). Patients with alcohol-related disease had a higher risk of mortality at 1 year after hip fracture.

CONCLUSIONS

Alcohol-related disease increases the risk of hip fracture significantly and reduces long-term survival. The present results suggest that patients hospitalized for alcohol-related disease should be targeted for hip fracture prevention programs.

The accuracy of diagnosis and procedural codes for patients with upper GI hemorrhage

BACKGROUND

Little is known about the accuracy of diagnostic and procedural codes for common gastrointestinal (GI) conditions and endoscopic procedures.

METHODS

Eight hundred eighty-two patients with upper GI hemorrhage admitted in 1994 to 1 of 13 regional hospitals were studied. Based on endoscopy reports, the source of hemorrhage, performance of upper endoscopy and use of endoscopic therapy were determined, and we assessed the sensitivity and positive predictive value of discharge codes for measuring the source of hemorrhage and use of upper endoscopy.

RESULTS

The sensitivity and positive predictive value of principal diagnosis coding for source of hemorrhage were typically 85% to 95%. The sensitivity and predictive value of coding for upper endoscopy were 97.7% and 99.9%, respectively, and were 72.3% and 99.4%, respectively, for endoscopic therapy. Accuracy did not differ between the 4 major teaching and 9 other hospitals.

CONCLUSIONS

Hospital-based diagnostic and procedural codes are a reasonably accurate source of data for clinical and outcomes analyses of upper GI hemorrhage. In particular, it is possible to discern from these data the source of hemorrhage and the overall use of upper endoscopy.

The association between hospital type and mortality and length of stay: a study of 16.9 million hospitalized Medicare beneficiaries

OBJECTIVES

To examine the association between hospital type and mortality and length of stay using hospitalized Medicare beneficiaries for a 10-year period.

METHODS

The retrospective cohort study included 16.9 million hospitalized Medicare beneficiaries > or = 65 years of age admitted for 10 common medical conditions and 10 common surgical procedures from 1984 to 1993. A total of 5,127 acute-care hospitals in the United States were grouped into 6 mutually exclusive hospital types based on teaching status and financial structure (for-profit [FP], not-for-profit [NFP], osteopathic [OSTEO], public [PUB], teaching not-for-profit [TNFP], and teaching public [TPUB]) as reported in the 1988 American Hospital Association database. Logistic and linear regression methods were used to examine risk-adjusted 30-day and 6-month mortality and length of stay.

RESULTS

During the 10-year study period, 10.6 million patients were admitted with 1 of the 10 selected medical conditions, and 6.3 million patients were hospitalized for 1 of the 10 selected surgical procedures. Patients at TNFP hospitals had significantly lower risk-adjusted 30-day mortality rates than patients at other hospital types when all diagnoses or procedures were combined (combined diagnoses: RR(TNFP) = 1.00 [reference], RR(TPUB) = 1.40, RR(OSTEO) = 1.14, RR(PUB) = 1.07, RR(FP) = 1.03, RR(NFP) = 1.02; combined procedures: RR(TNFP) = 1.00 [reference], RR(OSTEO) = 1.36, RR(TPUB) = 1.30, RR(PUB) = 1.16, RR(FP) = 1.13, RR(NFP) = 1.08). The results were mostly consistent when diagnoses and procedures were examined separately. After adjustment for patient characteristics, patients at other hospital types had 10% to 20% shorter lengths of stay (LOS) than patients at TNFP hospitals for most diagnoses and procedures studied.

CONCLUSION

As measured by the risk-adjusted 30-day mortality, TNFP hospitals had an overall better performance than other hospital types. However, patients at TNFP hospitals had relatively longer LOS than patients at other hospital types, perhaps reflecting the medical education and research activities found at teaching institutions. Future research should examine the empirical evidence to help elucidate the adequate LOS for a given condition or procedure while maintaining the quality of care.

The relationship of gender and in-hospital death: increased risk of death in men

OBJECTIVES

The prognostic importance of gender in hospitalized patients has been poorly studied. The current study compared in-hospital death rates between men and women after adjusting for severity of illness.

DESIGN

Retrospective cohort study.

PATIENTS

89,793 eligible patients with 6 common nonsurgical diagnoses who were discharged from 30 hospitals in Northeast Ohio in 1991 to 1993.

METHODS

Admission severity of illness (ie, predicted risk of death) was calculated using multivariable models that were based on data abstracted from patients' clinical records (ROC curve areas, 0.83-0.90). In hospital death rates were then adjusted for predicted risks of death and other covariates using logistic regression analysis.

RESULTS

Adjusted odds of death were higher (P < 0.05) in men, compared with women, for 4 diagnoses (stroke [OR, 1.60]; obstructive airway disease [OR, 1.38]; gastrointestinal hemorrhage [OR 1.32]; pneumonia [OR, 1.18]) and similar for two diagnoses (congestive heart failure [OR, 1.12]; and acute myocardial infarction [OR, 0.97]). These differences were somewhat attenuated by excluding patients discharged to skilled nursing facilities or other hospitals from analysis; nonetheless, the odds of death in men remained higher for 3 diagnoses.

CONCLUSIONS

The findings indicate that inhospital death rates are generally higher in men than in women, after adjusting for severity of illness. In addition, the risk of in-hospital death in men and women was influenced by diagnosis. These differences may reflect gender-related variation in the utilization of hospital services, the effectiveness of care, over- or underestimation of severity of illness, or biological differences in men and women.