Thirty-Day Readmission Among Patients With Non-Variceal Upper Gastrointestinal Hemorrhage and Effects on Outcomes

The Role of Hospital Characteristics in Clinical and Quality Outcomes for Gastrointestinal Bleeding in a National Cohort

INTRODUCTION

There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes.

METHODS

This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality.

RESULTS

Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services.

DISCUSSION

Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB.

Ulcer Bleeding in the United States: Epidemiology, Treatment Success, and Resource Utilization

BACKGROUND AND GOALS

Peptic ulcer disease is the most frequent cause of upper gastrointestinal bleeding. We sought to establish the epidemiology and hemostasis success rate of the different treatment modalities in this setting.

METHODS

Retrospective cohort study using the National Inpatient Sample. Non-elective adult admissions with a principal diagnosis of ulcer bleeding were included. The primary outcome was endoscopic, radiologic and surgical hemostasis success rate. Secondary outcomes were patients' demographics, in-hospital mortality and resource utilization. On subgroup analysis, gastric and duodenal ulcers were studied separately. Confounders were adjusted for using multivariate regression analysis.

RESULTS

A total of 136,425 admissions (55% gastric and 45% duodenal ulcers) were included. The mean patient age was 67 years. The majority of patients were males, Caucasians, of lower income and high comorbidity burden. The endoscopic, radiological and surgical therapy and hemostasis success rates were 33.6, 1.4, 0.1, and 95.1%, 89.1 and 66.7%, respectively. The in-hospital mortality rate was 1.9% overall, but 2.4% after successful and 11.1% after failed endoscopic hemostasis, respectively. Duodenal ulcers were associated with lower adjusted odds of successful endoscopic hemostasis, but higher odds of early and multiple endoscopies, endoscopic therapy, overall and successful radiological therapy, in-hospital mortality, longer length of stay and higher total hospitalization charges and costs.

CONCLUSIONS

The ulcer bleeding endoscopic hemostasis success rate is 95.1%. Rescue therapy is associated with lower hemostasis success and more than a ten-fold increase in mortality rate. Duodenal ulcers are associated with worse treatment outcomes and higher resource utilization compared with gastric ulcers.

The Influence of Hospital Type, Insurance Type, and Patient Income on 30-Day Complication and Readmission Rates Following Lumbar Spine Fusion

BACKGROUND CONTEXT

Several studies have shown that factors such as insurance type and patient income are associated with different readmission rates following certain orthopaedic procedures. The literature, however, remains sparse with regard to these demographic characteristics and their associations to perioperative lumbar spine fusion outcomes.

PURPOSE

The purpose of this study was to assess the associations between hospital type, insurance type, and patient median income to both 30-day complication and readmission rates following lumbar spine fusion.

PATIENT SAMPLE

Patients who underwent primary lumbar spine fusion (n = 596,568) from 2010-2016 were queried from the National Readmissions Database (NRD).

OUTCOME MEASURES

Incidence of 30-day complication and readmission rates.

METHODS

All relevant diagnoses and procedures were identified using International Classification of Disease, 9th and 10th Edition (ICD-9, 10) codes. Hospital types were categorized as metropolitan non-teaching (n = 212,131), metropolitan teaching (n = 364,752), and rural (n = 19,685). Insurance types included: Medicare (n = 213,534), Medicaid (n = 78,520), private insurance (n = 196,648), and out-of-pocket (n = 45,025). Patient income was divided into the following quartiles: Q1 (n = 112,083), Q2 (n = 145,755), Q3 (n = 156,276), and Q4 (n = 147,289), wherein quartile 1 corresponded to lower income ranges and quartile 4 to higher ranges. Statistical analysis was conducted in R. Kruskal-Wallis tests with Dunn's pairwise comparisons were performed to analyze differences in 30-day readmission and complication rates in patients who underwent lumbar spine fusion. Complications analyzed included infection, wound injury, hematoma, neurological injury, thromboembolic event, and hardware failure.

RESULTS

30-day readmission was significantly higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals and rural hospitals (P < .05). Patients from metropolitan teaching hospitals had significantly higher rates of infection (P < .001), wound injury (P < .001), hematoma (P = .018), and hardware failure (P < .002) compared to those treated at metropolitan non-teaching hospitals. Privately insured patients were significantly less likely to be readmitted at 30 days than those paying with Medicare or Medicaid (P < .01). Patients with private insurance also experienced significantly lower rates of hematoma formation than Medicare beneficiaries and out-of-pocket payers (P < .01), postoperative wound injury compared to Medicaid patients and out-of-pocket payers (P < .005), and infection compared to all other groups (P < .001). Patients in Quartile 4 experienced significantly greater rates of hematoma formation compared to those in Quartiles 1 and 2 and were more likely to experience a thromboembolic event compared to all other groups.

CONCLUSION

Patients undergoing lumbar spine fusion at metropolitan non-teaching hospitals and paying with private insurance had significantly lower 30-day readmission rates than their counterparts. Complications within 30 days following lumbar spine fusion were significantly higher in patients treated at metropolitan teaching hospitals and in Medicare and Medicaid beneficiaries. Aside from a few exceptions, however, patient income was generally not associated with differential complication rates.

Outcomes of Nonvariceal Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A National Analysis

GOALS

We sought to evaluate hospital outcomes of cirrhosis patients with nonvariceal upper gastrointestinal bleeding (NVUGIB).

BACKGROUND

NVUGIB is common in patients with cirrhosis. However, national outcome studies of these patients are lacking.

STUDY

We utilized the 2014 Nationwide Readmission Database to evaluate NVUGIB in patients with cirrhosis, further stratified as no cirrhosis (NC), compensated cirrhosis (CC), or decompensated cirrhosis (DC). Validated International Classification of Diseases, Ninth Revision, Clinical Modification codes captured diagnoses and interventions. Outcomes included 30-day readmission rates, index admission mortality rates, health care utilization, and predictors of readmission and mortality using multivariable regression analysis.

RESULTS

Overall, 13,701 patients with cirrhosis were admitted with NVUGIB. The 30-day readmission rate was 20.8%. Patients with CC were more likely to undergo an esophagogastroduodenoscopy (EGD) within 1 calendar day of admission (74.1%) than patients with DC (67.9%) or NC (69.4%). Patients with DC had longer hospitalizations (4.1 d) and higher costs of care ($11,834). The index admission mortality rate was higher in patients with DC (6.2%) than in patients with CC (1.7%, P <0.001) or NC (1.4%, P <0.001). Predictors of 30-day readmission included performing an EGD >1 calendar day from admission (OR: 1.21; 95% CI, 1.00 to 1.46) and DC (OR: 1.78; 95% CI, 1.54 to 2.06). DC was a predictor of index admission mortality (OR: 3.68; 95% CI, 2.67 to 5.05).

CONCLUSIONS

NVUGIB among patients with DC is associated with higher readmission rates, mortality rates, and health care utilization compared with patients with CC and NC. Early EGD is a modifiable variable associated with reduced readmission rates. Early identification of high-risk patients and adherence to guidelines may improve clinical outcomes.

Impact of sleep apnoea on 30 day hospital readmission rate and cost in heart failure with reduced ejection fraction

AIMS

In this study, we estimated the 30 day all-cause and heart failure-specific readmission rates, predictors, mortality, and hospitalization costs in patients with obstructive sleep apnoea admitted with acute decompensated heart failure with reduced ejection fraction.

METHODS AND RESULTS

This is a retrospective cohort study using the Agency of Healthcare Research and Quality's National Readmission Database for the year 2019. The primary outcome was the 30 day all-cause hospital readmission rate. The secondary outcomes were (i) in-hospital mortality rate for index admissions; (ii) 30 day mortality rate for index hospitalizations; (iii) the five most common principal diagnosis for readmission; (iv) readmission in-hospital mortality rate; (v) length of hospital stay; (vi) independent risk factors for readmission; and (vii) hospitalization costs. We identified 6908 hospitalizations that met our study definition. The mean patient age was 62.8 years, and women comprised only 27.6% of patients. The 30 day all-cause readmission rate was 23.4%. 48.9% of readmissions were due to decompensated heart failure. The in-hospital mortality rate during readmissions was significantly higher than that of the index admission (5.6% vs. 2.4%; P < 0.05). The mean length of stay for patients during index admissions was 6.5 days (6.06-7.02), while during readmissions, it was 8.5 days (7.4-9.6; P < 0.05). The mean total hospitalization charges at index admissions were $78 438 (68 053-88 824), while during readmissions, they were higher at $124 282 (90 906-157 659; P < 0.05). The mean total cost of hospitalization during index admissions was $20 535 (18 311-22 758), while at readmissions, it was higher at $29 954 (24 041-35 867; P < 0.05). The total hospital charges for all 30 day readmissions were $195 million, and total hospital costs was $46.9 million. The variables found to be associated with increased rate of readmissions were patients with Medicaid insurance, higher Charlson co-morbidity Index, and longer length of stay. The variables associated with lower rate of readmissions were prior percutaneous coronary intervention and patients with private insurance.

CONCLUSIONS

In patients with obstructive sleep apnoea admitted with heart failure with reduced ejection fraction, we found a substantial all-cause readmission rate of 23.4% with heart failure readmission constituting about 48.9% of readmissions. Readmissions were associated with higher mortality and resource use.

Risk factors associated with 30-day hospital readmissions among persons living with HIV in Nantong, China

OBJECTIVE

To estimate 30-day hospital readmission rates among persons living with HIV (PLWH) at the Nantong Infectious Disease Hospital in China and analyse the related risk factors.

METHODS

A single-centre retrospective cohort study was conducted. There were 894 PLWH records obtained from the electronic medical record (EMR) system at the Nantong Infectious Disease Hospital in China, from October 2013 to February 2018. The 30-day readmission rates were calculated, and the risk factors were analysed by generalised estimating equations (GEEs).

RESULTS

A total of 1153 hospitalizations from 894 patients were recorded between October 2013 and February 2018. The median time of 30-day readmissions was 13 days (interquartile range (IQR), 6-23). The reasons for all causes, acquired immunodeficiency syndrome (AIDS)-defining illnesses (ADIs), and non-AIDS-defining infections (non-ADIs) were 9.08, 13.52, and 7.91%, respectively. The results from the GEE analysis demonstrated that the risk factors associated with 30-days readmissions were as follows: no antiretroviral therapy (ART) prior to hospitalisations (odds ratio (OR) = 1.90, 95% confidence interval (CI): 1.21-3.00), low CD4 counts (OR = 2.17, 95% CI: 1.33-3.54), and multiple comorbidities (OR = 6.45, 95% CI: 1.62-25.73).

CONCLUSION

Early detection of HIV infection and early initiation of ART treatment are the keys to controlling 30-day readmissions.

Characteristics of 30-Day All-Cause Hospital Readmissions Among Patients with Acute Pancreatitis and Substance Use

BACKGROUND/OBJECTIVES

Previous studies on healthcare resource utilization and 30-day readmission risks among patients with acute pancreatitis (AP) have focused upon opioid and alcohol use. The data on other substance types are lacking. In this study we aim to estimate the 30-day readmission rates, predictors of readmission, impact of readmission on patient outcomes and resulting economic burden among patients with AP and substance use in the USA.

METHODS

This was a retrospective cohort study, based upon data from 2017 National Readmission Database of adult patients with AP and substance use (alcohol in combination, opioid, cannabis, cocaine, sedatives, other stimulants, other hallucinogens, other psychoactive, inhalant and miscellaneous). We estimated the 30-day readmission rates and predictors of 30-day readmission.

RESULTS

Among 25,795 eligible patients, most were male, belonged to the lower income quartile, resided in the urban facility and had a Charlson comorbidity score of 0 or 1. The use of a combination of substances was the most common in 17,265 (66.9%) patients followed by only opioids in 4691 (18.2%) patients and only marijuana in 3839 (14.9%) patients. A total of 14.6% patients were readmitted within 30 days after discharge for non-elective causes with the highest risk of readmission within the 1st week after discharge with 5.2% readmissions. Among top ten causes of readmission, most of the principal diagnosis were related to AP in 53.1%. Compared to index admission, readmitted patients had significantly higher rates of acute cardiac failure, shock, and higher in-hospital mortality rate. Overall, readmission attributed to an additional 17,801 days of hospitalization resulting in a total of $150 million in hospitalization charges and $36 million in hospitalization costs in 2017. On multivariate analysis, chronic pancreatitis, self-discharge against medical advice, treatment at the highest volume centers, higher Charlson comorbidity index, increasing length of stay and severe disease were associated with higher odds of readmission while female gender and private insurance were associated with lower odds.

CONCLUSION

Readmission was associated with higher morbidity and in-hospital mortality among patients with AP and substance use and resulted in a significant monetary burden on the US healthcare system. Several factors identified in this study may be useful for categorizing patients at higher risk of readmission warranting special attention during discharge planning.

Development and Validation of a nomogram for forecasting survival of alcohol related hepatocellular carcinoma patients

BACKGROUND

With the increasing incidence and prevalence of alcoholic liver disease, alcohol-related hepatocellular carcinoma has become a serious public health problem worthy of attention in China. However, there is currently no prognostic prediction model for alcohol-related hepatocellular carcinoma.

METHODS

The retrospective analysis research of alcohol related hepatocellular carcinoma patients was conducted from January 2010 to December 2014. Independent prognostic factors of alcohol related hepatocellular carcinoma were identified by Lasso regression and multivariate COX proportional model analysis, and the nomogram model was constructed. The reliability and accuracy of the model were assessed using the concordance index(C-Index), receiver operating characteristic (ROC) curve and calibration curve. Evaluate the clinical benefit and application value of the model through clinical decision curve analysis (DCA). The prognosis was assessed by the Kaplan-Meier (KM) survival curve.

RESULTS

In sum, 383 patients were included in our study. Patients were stochastically assigned to training cohort (n=271) and validation cohort (n=112) according to 7:3 ratio. The predictors included in the nomogram were splenectomy, platelet count (PLT), creatinine (CRE), Prealbumin (PA), mean erythrocyte hemoglobin concentration (MCHC), red blood cell distribution width (RDW) and TNM. Our nomogram demonstrated excellent discriminatory power (C-index) and good calibration at 1-year, 3-year and 5- year overall survival (OS). Compared to TNM and Child-Pugh model, the nomogram had better discriminative ability and higher accuracy. DCA showed high clinical benefit and application value of the model.

CONCLUSION

The nomogram model we established can precisely forcasting the prognosis of alcohol related hepatocellular carcinoma patients, which would be helpful for the early warning of alcohol related hepatocellular carcinoma and predict prognosis in patients with alcoholic hepatocellular carcinoma.

Hospital Performance for Gastrointestinal Bleeding Mortality, Length of Stay, and Complication Rates in the USA

BACKGROUND

Hospitals are held accountable for quality metrics, through public reporting programs and by payers. However, little is known about hospital performance in GIB nationally.

METHODS

A retrospective longitudinal analysis utilizing Vizient's database was performed to identify GIB hospitalizations across 349 hospitals from 2016 to 2018. The primary outcome was risk-adjusted mortality; secondary outcomes included risk-adjusted length of stay and complication rate. Trends in performance were characterized using quintiles, with analysis of concordance within hospitals and across hospitals over time. Pearson's correlation coefficients were performed to assess the relationship among metrics.

RESULTS

28.1% of hospitals had a steadily improving risk-adjusted mortality index from 2016 to 2018, while 15.5% were steadily worsening in mortality. For LOS, 25.2% of hospitals were improving, while 22.4% deteriorated. For complication rate, 22.9% of hospitals steadily improved, while 19.2% of hospitals deteriorated. Although many hospitals improved substantially in one outcome, they did not necessarily improve in all outcomes. Of the 98 hospitals that steadily improved in mortality from 2016 to 2018, only 8 out of 98 steadily improved in all three outcomes (8.3%). Across all 3 years, mortality was weakly correlated with LOS (r = 0.22, p < 0.001), but not with the rate of complications (r = 0.08, p = 0.12).

CONCLUSION

Hospital performance metrics for GIB, such as mortality, length of stay, and complication rate, are weakly correlated and thus likely measure different aspects of care. While many hospitals improved over time, few hospitals improved in all three metrics. Additionally, many hospitals are deteriorating over time, and further research is needed to determine which care processes are associated with better outcomes.

Association of alpha-fetoprotein and metastasis for small hepatocellular carcinoma: A propensity-matched analysis

Metastasis is crucial for the prognosis of hepatocellular carcinoma (HCC). Distinguishing the potential risk factors for distant metastasis in small HCC (diameter ≤ 5 cm) is of great significance for improving the prognosis. HCC patients in the Surveillance, Epidemiology and End Results (SEER) registry with tumors ≤ 5 cm in diameter between January 2010 and December 2015 were retrieved. Demographic and clinicopathological metrics were extracted, including age, sex, race, marital status, tumor size, histological grade, T stage, N stage, M stage, alpha-fetoprotein (AFP), and liver fibrosis score. Univariate and multivariate logistic regression analyses were used to identify independent risk factors correlated with extrahepatic metastasis in small HCC. Propensity score matching (PSM) analysis was performed to balance the confounding factors in baseline characteristics. A total of 4176 eligible patients were divided into a non-metastasis group (n = 4033) and a metastasis group (n = 143) based on metastasis status. In multivariate analysis, larger tumor size, poor histological differentiation, regional lymph node metastasis, and elevated serum AFP levels were identified as independent risk factors for distant metastasis (P < 0.05), while age, sex, race, marital status, and liver fibrosis score were not associated with extrahepatic metastasis. After propensity score analysis, the AFP level was no longer associated with metastatic risk. The present study provided no evidence for a correlation between the clinical threshold of AFP and metastasis in small hepatocellular carcinoma.

Outcomes and Resource Utilization in Patients Hospitalized with Gastrointestinal Bleeding Complicated by Types 1 and 2 Myocardial Infarction

BACKGROUND

Types 1 and 2 myocardial infarction (MI) may occur in the setting of gastrointestinal bleeding (GIB). There is a paucity of data pertinent to the contemporary prevalence and impact of types 1 and 2 MI following GIB. We examined clinical profiles and the prognostic impact of both MI types on outcomes of patients hospitalized with GIB.

METHODS

The 2018 Nationwide Readmission Database was queried for patients hospitalized for the primary diagnosis of GIB and had concomitant diagnoses of type 1 or type 2 MI. Baseline characteristics, in-hospital mortality, resource utilization, and 30-day all-cause readmissions were compared among groups.

RESULTS

Of 381,867 primary GIB hospitalizations, 2902 (0.75%) had type 1 MI and 3963 (1.0%) had type 2 MI. GIB patients with type 1 and type 2 MI had significantly higher in-hospital mortality compared to their counterparts without MI (adjusted odds ratios [aOR]: 4.72, 95% confidence interval [CI] 3.43-6.48; and aOR: 2.17, 95% CI 1.48-3.16, respectively). Both types 1 and 2 MI were associated with higher rates of discharge to a nursing facility (aOR of type 1 vs. no MI: 1.65, 95% CI 1.45-1.89, and aOR of type 2 vs no MI: 1.37, 95% CI 1.22-1.54), longer length of stay, higher hospital costs, and more 30-day all-cause readmissions (aOR of type 1 vs no MI: 1.22, 95% CI 1.08-1.38; aOR of type 2 vs no MI: 1.17, 95% CI 1.05-1.30).

CONCLUSION

Types 1 and 2 MI are associated with higher in-hospital mortality and resource utilization among patients hospitalized with GIB in the United States.

Development and Validation of a Website to Guide Decision-Making for Disorders of Consciousness

Background

This study aimed to develop and validate a nomogram and present it on a website to be used to predict the overall survival at 16, 32, and 48 months in patients with prolonged disorder of consciousness (pDOC).

Methods

We retrospectively analyzed the data of 381 patients with pDOC at two centers. The data were randomly divided into training and validation sets using a ratio of 6:4. On the training set, Cox proportional hazard analyses were used to identify the predictive variables. In the training set, two models were screened by COX regression analysis, and based on clinical evidence, model 2 was eventually selected in the nomogram after comparing the receiver operating characteristic (ROC) of the two models. In the training and validation sets, ROC curves, calibration curves, and decision curve analysis (DCA) curves were utilized to measure discrimination, calibration, and clinical efficacy, respectively.

Results

The final model included age, Glasgow coma scale (GCS) score, serum albumin level, and computed tomography (CT) midline shift, all of which had a significant effect on survival after DOCs. For the 16-, 32-, and 48-month survival on the training set, the model had good discriminative power, with areas under the curve (AUCs) of 0.791, 0.760, and 0.886, respectively. For the validation set, the AUCs for the 16-, 32-, and 48-month survival predictions were 0.806, 0.789, and 0.867, respectively. Model performance was good for both the training and validation sets according to calibration plots and DCA.

Conclusion

We developed an accurate, efficient nomogram, and a corresponding website based on four correlated factors to help clinicians improve their assessment of patient outcomes and help personalize the treatment process and clinical decisions.

Cannabis Use is Associated With Reduced 30-Day All-cause Readmission Among Hospitalized Patients With Irritable Bowel Syndrome: A Nationwide Analysis

BACKGROUND

Cannabinoid receptors are potential therapeutic targets in a variety of gastrointestinal tract disorders. The authors hypothesize that the use of cannabis use is associated with better control of symptoms associated with irritable bowel syndrome (IBS). This study aimed to examine the utilization of inpatient services by patients with IBS who did and did not report the use of cannabis.

METHODS

This is a retrospective cohort study that utilized the 2016 Nationwide Readmissions Database. Inclusion criteria included a principal diagnosis of IBS. The primary outcome was 30-day hospital readmission rates for IBS-specific causes. Secondary outcomes included the 30-day hospital readmission rates for all causes, resource utilization, and the 5 most common principal diagnoses and independent risk factors associated with readmission.

RESULTS

Of the 7163 patients with IBS identified in the National Readmission Database, 357 reported the use of cannabis. The 30-day IBS-specific readmission rates were 1.5% in patients who reported cannabis use and 1.1% in those who did not report cannabis use (P=0.53). Among the cannabis users, none of the variables evaluated served as a significant predictor of IBS-specific readmission; median income was a predictor for readmission among those who did not report cannabis use (odds ratio, 2.77; 95% confidence interval, 1.15-6.67; P=0.02). The 30-day readmission rates for all causes were 8.1% and 12.7% for patients who did and did not report cannabis use, respectively. After adjusting for confounders, the odds of 30-day readmission for all causes were lower among patients who reported cannabis use compared with those who did not (adjusted odds ratio, 0.53; 95% confidence interval, 0.28-0.99; P=0.04). The 5 most frequent diagnoses at readmission among patients who did not report cannabis use were enterocolitis because of Clostridioides difficile, IBS without diarrhea, sepsis, noninfective gastroenteritis and colitis, and acute kidney failure. By contrast, the 5 most frequent readmission diagnoses for cannabis users were cyclical vomiting, IBS with diarrhea, endometriosis, right upper quadrant abdominal pain, and nausea with vomiting. A discharge disposition of "against medical advice" was identified as an independent risk factor for 30-day hospital readmission for all causes among patients who reported cannabis use. By contrast, higher comorbidity scores and discharges with home health care were independent predictors of 30-day hospital readmission for all causes among patients who did not report cannabis use. Private insurance was an independent factor associated with lower rates of readmission for all causes among those who did not report cannabis use.

CONCLUSION

Our review of the National Readmission Database revealed no statistically significant differences in 30-day readmission rates for IBS-specific causes when comparing patients who reported cannabis use with those who did not. However, the authors found that cannabis use was associated with reduced 30-day hospital readmission rates for all causes.

Thirty-day readmission rates, reasons, and costs for gastrointestinal angiodysplasia-related bleeding in the USA

BACKGROUND

Patients with gastrointestinal angiodysplasia (GIA)-related bleeding are at high risk for readmissions, resulting in significant morbidity and an economic burden on the healthcare system.

AIM

The aim of the study was to determine the 30-day readmission rate with reasons, predictors, and costs associated with GIA-related bleeding in the USA.

METHODS

We queried the National Readmission Database to identify patients hospitalized with GIA-related bleeding in the year 2016 using the International Classification of Diseases, Tenth Revision (ICD-10) codes. Primary outcomes included the 30-day readmission rate, and secondary outcomes were in-hospital mortality and resource utilization for index and re-hospitalizations. We also performed univariate and multivariate cox regression analysis to identify predictors of readmissions.

RESULTS

A total of 25 079 index hospitalizations for GIA-related bleeding were identified in 2016. Out of these, 5047 (20.34%) patients got readmitted within the next 30 days. The most common diagnosis associated with readmissions were related to recurrent gastrointestinal bleeding. Readmissions compared to index hospitalization has significantly higher length of stay (5.38 vs. 5.11 days, P = 0.03), but mean hospitalization charges ($52 114 vs. $49 691, P = 0.11) and mean total hospitalization costs ($12 870 vs. $12 405, P = 0.16) were similar. Patients with multiple co-morbidities, length of stay >5 days, and end-stage renal disease were found to be independent predictors for 30-day readmissions.

CONCLUSION

Our study shows that one in five patients hospitalized with GIA-related bleeding was readmitted within 30 days of index hospitalization, placing a heavy economic burden on the healthcare system. Further research identifying strategies to reduce readmissions in these patients is needed.

Impact of time to esophagogastroduodenoscopy in patients with nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis

INTRODUCTION

There is conflicting evidence regarding the benefit of urgent esophagogastroduodenoscopy (EGD) for reducing mortality and rebleeding, in the context of nonvariceal upper gastrointestinal bleeding.

AIM

To describe the decrease in the risk for mortality, rebleeding, and red blood cell transfusion, with the performance of urgent EGD, in patients with nonvariceal upper gastrointestinal bleeding.

MATERIALS AND METHODS

We carried out a search for cohort studies or controlled clinical trials, published from December 1966 to May 2020, that compared urgent EGD versus elective EGD in the management of adults with nonvariceal upper gastrointestinal bleeding, utilizing the MEDLINE, Embase, LILACS, and Cochrane Central Register of Controlled Trials databases. Our primary outcome was the hospital mortality comparison. The incidence of rebleeding and the mean number of red blood cell units transfused were also compared. A random effects model was utilized for the meta-analysis.

RESULTS

Twenty-one studies that met the eligibility criteria were included, involving 489,622 patients. We found no differences in the mortality of subjects exposed to urgent EGD versus elective EGD (RR 1.12 [0.72-1.72]). There was a significant increase in the risk for rebleeding (RR 1.30 [1.05-1.60]) in the subjects exposed to urgent EGD, and fewer red blood cell units were transfused in those patients (RR 0.52 [0.05-0.99]).

CONCLUSIONS

Urgent EGD in subjects with nonvariceal upper gastrointestinal bleeding does not appear to have a significant impact on short-term mortality.

A Protocol for a Systematic Review and Meta-Analysis of Hospital Readmissions Following Acute Upper Gastrointestinal Bleeding

This protocol outlines the planned methodology for a systematic review and meta-analysis. The primary objective of the review is to identify all-cause readmission rates for individuals hospitalized for an upper GI bleed (UGIB). Secondary objectives will include GI bleed-specific readmission rates, mortality (all-cause and GI bleed-specific), readmission diagnosis, and length of stay on readmission visit. High-risk subgroups will also be explored including age, sex, type of GI bleed (e.g., variceal or not), anti-coagulation status, and comorbidity status. Through this review, the research team aims to describe an important quality indicator, which has implications for both patient safety post-discharge after an UGIB and healthcare resource utilization.

90-Day Specific Readmission for Clostridium difficile Infection After Hospitalization With an Inflammatory Bowel Disease Flare: Outcomes and Risk Factors

BACKGROUND

Patients with inflammatory bowel disease (IBD) have an increased risk for Clostridium difficile infection (CDI) and carry significantly higher morbidities and mortality than those without IBD. We aimed to investigate disease-specific readmission rates and independent risk factors for CDI within 90 days of an index hospitalization for an IBD flare.

METHODS

The Nationwide Readmission Database was queried for the year 2016. We collected data on hospital readmissions of 50,799 adults who were hospitalized for urgent IBD flare and discharged. The primary outcome was disease-specific readmission rate for CDI within 90 days of discharge. The secondary outcomes were readmission rate of colonoscopic procedures, morbidities (including mechanical ventilation and shock), and hospital economic burden. The risk factors for readmission were identified using Cox regression analysis.

RESULTS

The 90-day specific readmission rate was 0.1% (N = 477). A total of 3,005 days were associated with readmission, and the total health care in-hospital economic burden of readmission was $19.1 million (in charges) and $4.79 million (in costs). Independent predictors during index admission for readmission were mechanical ventilation for >24 hours (hazard ratio [HR], 6.62, 95% confidence interval [CI], 0.80-54.57); history of previous CDI (HR, 5.48; 95% CI, 3.66-8.19); HIV-positive status (HR, 4.60; 95% CI, 1.03-20.50); alcohol abuse disorders (HR, 2.06; 95% CI, 1.15-3.70); Parkinson's disease (HR, 4.68; 95% CI, 1.65-13.31); index admission for noncomplicated ulcerative colitis (HR, 4.72; 95% CI, 2.99-7.45]-), complicated ulcerative colitis (HR, 4.49; 95% CI, 2.80- 7.18), or noncomplicated Crohn disease (HR, 2.54; 95% CI, 2.80-4.04); and hospital length of stay (HR, 1.01; 95% CI, 1.01-1.02).

CONCLUSIONS

The 90-day CDI-specific readmission rate after the index admission of IBD flares was 0.1%. We found risk factors for CDI-associated readmissions such as history of Parkinson's disease, prior CDI, HIV-positive status, and alcohol abuse disorder. Finally, our study also revealed a high health care cost, charges, and burden.

Acute biliary pancreatitis has better outcomes but increased resource utilization compared to acute alcohol-induced pancreatitis: insights from a nationwide study

Background

The differences in outcomes between acute biliary pancreatitis (ABP) and acute alcohol-induced pancreatitis (AAP) have not been well studied. We sought to examine the differences between ABP and AAP as regards to in-hospital outcomes and resource utilization, using a large nationwide database.

Methods

We queried the National Inpatient Sample databases 2016 and 2017 using the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) coding system to identify the patients with a primary diagnosis of AAP and ABP. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were hospital length of stay (LOS), hospitalization charge/cost, shock, acute kidney injury (AKI), intensive care unit (ICU) admission, and home discharge. Analysis was performed with STATA software.

Results

There was no significant difference in mortality between patients with AAP and ABP (0.42% vs. 0.82%, adjusted odds ratio [aOR] 0.95, 95% confidence interval [CI] 0.69-1.31; P=0.79). Patients with ABP had a significantly longer LOS (+0.48 days, P<0.001). Patients with ABP had significantly higher adjusted mean hospitalization charges ($+19,958, P<0.001) and costs ($+4,848, P<0.001). Patients with ABP had a significantly lower likelihood of shock (aOR 0.75, 95%CI 0.59-0.95; P=0.02), AKI (aOR 0.76, 95%CI 0.71-0.82; P<0.001) or ICU admission (aOR 0.74, 95%CI 0.62-0.88; P=0.001). They were more likely to be discharged home (aOR 1.26, 95%CI 1.18-1.34; P<0.001).

Conclusion

Although there was no difference in all-cause mortality, patients with ABP had better hospitalization outcomes but greater resource utilization.

Readmissions Rates After Myocardial Infarction for Gastrointestinal Bleeding: A National Perspective

BACKGROUND AND AIMS

Gastrointestinal (GI) bleeding is one most common complications of acute myocardial infarction (AMI). We aimed to determine the incidence, in-hospital outcomes, associated healthcare burden and predictors of GI bleeding within 30 days after AMI.

METHODS

Data were extracted from Nationwide Readmission Database 2010-2014. Patients were included if they had a primary diagnosis of ST or non-ST elevation myocardial infarction. Exclusion criteria were admissioned in December, aged less than 18 years and a diagnosis of type-2 MI. The primary outcome was 30-day readmission with upper or lower GI bleeding. Secondary outcomes were in-hospital mortality, etiology of bleeding, in-hospital complications, procedures, length of stay, and total hospitalization charges. Independent predictors of readmission were identified using multivariate logistic regression analysis.

RESULTS

Out of the 3,520,241 patients discharged with ACS, 10,018 (0.3%) were readmitted with GI bleeding within 30 days of discharge. 60% had lower GI bleeding. Most common sources suspected were GI cancers in 17% and hemorrhoidal bleeding in 10%. In hospital mortality rate for readmission was 3.6%. Independent predictors of readmission were age, Charlson comorbidity score, history of chronic kidney disease, GI tumor, inflammatory bowel disease and artificial heart valve. Type of treatment for AMI had no impact on readmission. Patients readmitted had higher rates of shock (adjusted odds ratio, 1.48, 95% CI 1.01-3.72).

CONCLUSIONS

In the first nationwide study, 30-day incidence of GI bleeding after AMI is 0.3%. GI bleeding complicating AMI carries a substantial in-hospital mortality and cost of care.

A simple-to-use web-based calculator for survival prediction in Parkinson's disease

Background: To establish and validate a nomogram and corresponding web-based calculator to predict the survival of patients with Parkinson’s disease (PD).

Methods: In this cohort study, we retrospectively evaluated patients (n=497) with PD using a two-stage design, from March 2004 to November 2007 and from July 2005 to July 2015. Predictive variables included in the model were identified by univariate and multiple Cox proportional hazard analyses in the training set.

Results: Independent prognostic factors including age, PD duration, and Hoehn and Yahr stage were determined and included in the model. The model showed good discrimination power with the area under the curve (AUC) values generated to predict 4-, 6-, and 8-year survival in the training set being 0.716, 0.783, and 0.814, respectively. In the validation set, the AUCs of 4- and 6-year survival predictions were 0.85 and 0.924, respectively. Calibration plots and decision curve analysis showed good model performance both in the training and validation sets. For convenient application, we established a web-based calculator (https://tangyl.shinyapps.io/PDprognosis/).

Conclusions: We developed a satisfactory, simple-to-use nomogram and corresponding web-based calculator based on three relevant factors to predict prognosis and survival of patients with PD. This model can aid personalized treatment and clinical decision-making.

Rates and Predictors of 30-Day Readmissions in Patients Undergoing Bariatric Surgery in the US: a Nationwide Study

BACKGROUND

Among various therapeutic options for morbid obesity, bariatric surgery (BS) is now considered one of the most effective methods of weight loss. We decided to perform an analysis to look at 30-day all-cause readmission and independent predictors of readmission in patients undergoing BS.

METHODS

We queried the 2017 Nationwide Readmission Database (NRD) using ICD-10-CM diagnosis codes to identify all adult patients who underwent BS from January 1 to November 30, 2017. Outcomes assessed were 30-day readmission rates, mortality, length of stay (LOS) and hospitalization costs, and independent predictors of readmission.

RESULTS

A total of 182,848 adult patients underwent BS during hospitalization in 2017, with in-hospital mortality rate of 0.52% (951). Of the patients discharged, 4.99% (9088) patients were readmitted within 30 days. The most common primary diagnosis at readmission was "Other complications of other bariatric surgery". When compared with index admission, readmitted patients had higher in-hospital mortality (0.52% vs 2.06%, p < 0.01), increased mean LOS (2.94 days vs 5.94 days, p < 0.01) but lower mean hospitalization charges ($67,763 vs $66,065, p < 0.01). Increasing age (HR 1.01, 95% CI: 1.006-1.014, p < 0.01), longer LOS (HR 1.01, 95% CI: 1.008-1.014, p < 0.01), higher comorbidity score (HR 1.15, 95% CI: 1.12-1.18, p < 0.01), CHF (HR 1.19, 95% CI: 1.01-1.42, p < 0.05), and AKI (HR 1.64, 95% CI: 1.34-2.02, p < 0.01) were independently associated with increased likelihood of 30-day readmission.

CONCLUSION

This study shows that almost 5% patients undergoing bariatric surgery are readmitted within 30 days of discharge in the US. Further studies are needed to assess the high-risk populations to understand the reasons predisposing to early readmission.

Nonvariceal upper GI hemorrhage after percutaneous coronary intervention for acute myocardial infarction: a national analysis over 11 months

BACKGROUND AND AIMS

Nonvariceal upper GI hemorrhage (NVUGIH) is a feared adverse event after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). We aimed to determine the incidence of NVUGIH after PCI for AMI and its impact on mortality, morbidity, and health care resource utilization over 11 months.

METHODS

We used the Nationwide Readmission Database 2014. Inclusion criteria were (1) a principal diagnosis of ST or non-ST-elevation myocardial infarction, (2) in-hospital PCI, and (3) admission in January. Exclusion criteria were age less than 18 years and elective admission. The primary outcome was the 11-month incidence of NVUGIH. Secondary outcomes were 11-month mortality rate, prolonged mechanical ventilation, shock, upper endoscopy, length of stay, and total hospitalization costs and charges. Independent risk factors for NVUGIH were identified using multivariate logistic regression analysis.

RESULTS

A total of 22,669 patients were included in the study. The mean age was 63.8 years (range, 63.4-64.1 years), and 31.7% of patients were female. The 11-month incidence of NVUGIH was 1.6%. The onset of NVUGIH was associated with an increase in the 11-month mortality rate (adjusted odds ratio, 1.94; 95% confidence interval, 1.01-3.72; P =.04). The upper endoscopy, shock, and prolonged mechanical ventilation rates were 72%, 6.2%, and 1.9%, respectively. In total, 26,532 days were associated with NVUGIH, with a total health care in-hospital economic burden of U.S.$17.6 million. Independent predictors of NVUGIH were female gender, Charlson comorbidity score, and length of stay.

CONCLUSIONS

The 11-month incidence of NVUGIH among patients who undergo PCI for AMI is 1.6%. NVUGIH has a substantial impact on mortality, morbidity, and in-hospital health care resource utilization.

Thirty-Day Readmission After Esophageal Variceal Hemorrhage and its Impact on Outcomes in the United States

AIMS

The authors sought to determine the 30-day readmission rate of patients with esophageal variceal hemorrhage (EVH) and its impact on mortality, morbidity, and health care utilization.

BACKGROUND

EVH is a common complication of cirrhosis and leads to substantial morbidity and mortality.

STUDY

The 2014 National Readmission Database was used to examine adult patients with urgent/emergent admissions and a principal diagnosis of EVH. The primary outcome was 30-day readmission. Secondary outcomes were in-hospital and 30-day mortality rate, most common reasons for readmission, readmission mortality rate, morbidity, and resource utilization. Independent risk factors for readmission were identified using multivariate regression analysis.

RESULTS

A total of 2003 patients with EVH were included. The mean age was 57 years and 29% of patients were female individuals. The all-cause 30-day readmission rate was 16.6%. EVH was the cause of readmission in only 5% of readmissions. Independent predictors of readmission were age and insurance type. The in-hospital and 30-day mortality rate for index admissions were 7.3% and 8.2%, respectively. For readmitted patients, the mortality rate was 3.9%. Although morbidity was lower during readmissions (prolonged mechanical ventilation: 0.4% vs. 3.5%, P<0.01 and shock: 1.8% vs. 9.9%, P<0.01), the cumulative additional length of stay was substantial at 2054 days with additional total hospitalization charges of US$20 million.

CONCLUSIONS

The all-cause 30-day readmission rate after EVH is 16.6%, with most patients being readmitted for diagnoses unrelated to EVH. Readmission was associated with a substantial increase in in-hospital mortality and resource utilization. Risk factors for readmission were identified, which can potentially be used to decrease readmission rates.

Epidemiology and Predictors of all-cause 30-Day readmission in patients with sickle cell crisis

The 30-day readmission rate after hospitalization for a sickle cell crisis (SCC) is extremely high. Accurate information on readmission diagnoses, total readmission costs and factors associated with readmission is required to effectively plan resource allocation and to plan interventions to reduce readmission rates. The present study aimed to examine readmission diagnoses and factors associated with all-cause 30-day readmission after hospitalization for SCC. We analyzed 2016 nationwide readmission database (NRD) to identify patterns of 30-day readmission by patient demographic characteristics and time after hospitalization for SCC. We estimated the percentage and most common readmission diagnoses for 30-day and 7-day readmissions after discharge. We studied the relationship between risk factors and readmission and the impact of readmission on patient outcomes and resulting financial burden on health care in dollars. In 2016, of 67,887 discharges after index hospitalizations, 18099 (26.9%) were readmitted within 30-days. Of all readmissions, 5166 (7.6%) were readmitted within 7 days. The spectrum of readmission diagnoses was largely similar in both 30-day and 7-day readmission with more than 80% patients in both time periods readmitted with diagnoses related to SCC. The mean length of stay for readmitted patients was significantly longer than the index hospitalization (5.3 days (5.1–5.5) vs 4.9 days (CI 4.8–5.1, p < 0.01). Also, the mean cost of hospitalization in readmitted patients $8485 was significantly higher than the index hospitalization $8064 p < 0.01. In 2016, readmission among patients with SCC incurred an additional 95,445 hospitalization days resulting a total charge of $609 million and a total cost of $152 million in the US. On Multivariate analysis, age group 18–30 years, discharge against medical advice, higher Charlson comorbidity index, low socioeconomic status and admission at high volume centers were associated with a higher likelihood of 30-day readmission. Among patients hospitalized for SCC, 30-day readmissions were frequent throughout the month post hospitalization and resulted in an enormous financial burden on the United States healthcare system.

A Simple-to-Use Nomogram for Predicting the Survival of Early Hepatocellular Carcinoma Patients

Objective: This study aimed to develop and validate a simple-to-use nomogram for early hepatocellular carcinoma (HCC) patients undergoing a preoperative consultation and doctors conducting a postoperative evaluation.

Methods: A total of 2,225 HCC patients confirmed with stage I or II were selected from the Surveillance, Epidemiology, and End Results database between January 2010 and December 2015. The patients were randomly divided into two groups: a training group (n = 1,557) and a validation group (n = 668). Univariate and multivariate hazards regression analyses were used to identify independent prognostic factors. The Akaike information criterion (AIC) was used to select variables for the nomogram. The performance of the nomogram was validated concerning its ability of discrimination and calibration and its clinical utility.

Results: Age, alpha-fetoprotein (AFP), race, the degree of differentiation, and therapy method were significantly associated with the prognosis of early HCC patients. Based on the AIC results, five variables (age, race, AFP, degree of differentiation, and therapy method) were incorporated into the nomogram. The concordance indexes of the simple nomogram in the training and validation groups were 0.707 (95% CI: 0.683–0.731) and 0.733 (95% CI: 0.699–0.767), respectively. The areas under the receiver operating characteristic (ROC) curve of the nomogram in the training and validation groups were 0.744 and 0.764, respectively, for predicting 3-year survival, and 0.786 and 0.794, respectively, for predicting 5-year survival. Calibration plots showed good consistency between the predictions of the nomogram and the actual observations in both the training and validation groups. Decision curve analysis (DCA) showed that the simple nomogram was clinically useful, and the overall survival significantly differed between low- and high-risk groups divided by the median score of the nomogram in the training group (P < 0.001).

Conclusion: A simple-to-use nomogram based on a large population-based study is developed and validated, which is a conventional tool for doctors to facilitate the individual consultation of preoperative patients and the postoperative personalized evaluation.

Gastrointestinal Endoscopy Editorial Board top 10 topics: advances in GI endoscopy in 2018

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed original endoscopy-related articles published during 2018 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of adenoma detection, bariatric endoscopy, EMR/submucosal dissection/full-thickness resection, artificial intelligence, expandable metal stents for palliation of biliary obstruction, pancreatic therapy with lumen-apposing metal stents, endoscope reprocessing, Barrett's esophagus, interventional EUS, and GI bleeding. This document summarizes these "Top 10" endoscopic advances of 2018.

Comparison of risk scores in upper gastrointestinal bleeding in western India: A prospective analysis

AIM

To study the upper gastrointestinal bleeding (UGIB) characteristics and to validate the Rockall and Glasgow-Blatchford scores (GBS), Progetto Nazionale Emorragica Digestiva (PNED) and albumin, international normalized ratio (INR), mental status, systolic blood pressure, and age > 65 (AIMS65) risk scores in predicting outcomes in patients with UGIB.

METHODS

Three hundred subjects with hematemesis and/or melena were prospectively enrolled and followed up for 30 days. All patients were assessed by hematological investigations, imaging, and endoscopy and risk scores were calculated.

RESULTS

The mean age was 43.5 ± 17.2 years, and 207 (69%) were males. Hematemesis was the most common presentation (94%). Variceal bleeding was the most common etiology (47.7%). Thirty patients died (10%) and 50 had rebleeding (16.7%). On univariate analysis, serum albumin ≤ 2.7 gm% (p = 0.008), Glasgow Coma scale ≤ 13.9 (p = 0.001), serum bilirubin > 3 mg/dL (p = 0.004), serum bicarbonate ≤ 15.7 mEq/L (p = 0.001), systolic blood pressure < 90 mmHg (p = 0.004), and arterial pH ≤ 7.3 (p = 0.003) were found to be the predictors of mortality. No variable was found significant on multivariate analysis. All four scores were significant in predicting mortality, but Rockall (area under receiver operating characteristic [AUROC] 0.728) was better than others. Rebleeding was better predicted by PNED (modified) (AUROC 0.705). In predicting the need for transfusion and surgical or radiological intervention, GBS score > 0 was significant while score of < 2 classified patients into low risk for mortality with high negative predictive value.

CONCLUSION

Our study showed that the variceal bleeding was the commonest cause of UGIB. Rockall score was more significant in predicting mortality while PNED for rebleeding. Low risk for mortality, need for blood transfusion, or interventions were accurately predicted by GBS.

Advances in management of nonvariceal upper gastrointestinal bleeding

PURPOSE OF REVIEW

To review new advances in managing nonvariceal upper gastrointestinal hemorrhage.

RECENT FINDINGS

Implementation of various scoring systems in combination with video capsule endoscopy assists in stratifying and managing nonvariceal upper gastrointestinal bleeding. New techniques such as thermocoagulation and hemoclips are useful to treat bleeding.

SUMMARY

The advancement of methods and procedures in managing nonvariceal upper gastrointestinal bleeding has decreased mortality of patients presenting with this type of hemorrhage. In this chapter, we will be discussing various scores to stratify nonvariceal upper gastrointestinal bleeding and techniques to stop bleeding.