Clinical Research Using the National Inpatient Sample: A Brief Review of Colorectal Studies Utilizing the NIS Database

Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery

BACKGROUND

Health equity in pain management during the perioperative period continues to be a topic of interest. The authors evaluated the association of race and ethnicity with regional anesthesia in patients who underwent colorectal surgery and characterized trends in regional anesthesia.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020, the research team identified patients who underwent open or laparoscopic colorectal surgery. Associations between race and ethnicity and use of regional anesthesia were estimated using logistic regression models.

RESULTS

The final sample size was 292,797, of which 15.6% (n = 45,784) received regional anesthesia. The unadjusted rates of regional anesthesia for race and ethnicity were 15.7% white, 15.1% Black, 12.8% Asian, 29.6% American Indian or Alaska Native, 16.3% Native Hawaiian or Pacific Islander, and 12.4% Hispanic. Black (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.96, p < 0.001) and Asian (OR 0.76, 95% CI 0.71-0.80, p < 0.001) patients had lower odds of regional anesthesia compared to white patients. Hispanic patients had lower odds of regional anesthesia compared to non-Hispanic patients (OR 0.72, 95% CI 0.68-0.75, p < 0.001). There was a significant annual increase in regional anesthesia from 2015 to 2020 for all racial and ethnic cohorts (p < 0.05).

CONCLUSION

There was an annual increase in the use of regional anesthesia, yet Black and Asian patients (compared to whites) and Hispanics (compared to non-Hispanics) were less likely to receive regional anesthesia for colorectal surgery. These differences suggest that there are racial and ethnic differences in regional anesthesia use for colorectal surgery.

Does obesity predict morbidity and mortality amongst patients undergoing transfemoral amputations?

BACKGROUND

We investigated the role of obesity on morbidity and mortality in patients undergoing above knee amputation.

METHODS

Data of 4225 patients undergoing AKAs was extracted from NIS Database (2016-2019) for a retrospectively matched case-control study and were grouped into; Non-obese (N-Ob-BMI <29.9 kg/m²; n = 1413), class I/II obese (Ob-I/II-BMI: 30-39.9 kg/m²; n = 1413), and class III obese groups (Ob-IIIBMI > 40; n = 1399). Morbidity, mortality, length of stay, and hospital charges were analyzed.

RESULTS

Blood loss anemia (OR = 1.42; 95% CI = 1.19-1.64), superficial SSI (OR = 5.10; 95% CI = 1.4717.63) and acute kidney injury (AKI- OR = 1.42; 95% CI = 1.21-1.67) were higher in Ob-III patients. Mortality was 5.8%, 4.5%, and 6.4% in N-Ob, Ob-I/II and Ob-III patients (p < 0.001; Ob-I/II vs. Ob-III), respectively. Hospital LOS was 3 days higher in Ob-III (16.1 ± 18.0), comparatively resulting in $25,481 higher inpatient-hospital charge.

CONCLUSION

Patients in Ob-III group were noted to have increased morbidity, higher LOS, and inpatient-hospital cost.

National Norms for the Elixhauser and Charlson Comorbidity Indexes Among Hospitalized Adults

BACKGROUND

Comorbidity burden is commonly measured among hospitalized adults, yet the U.S. national norms for 2 commonly used comorbidity indexes have not yet been reported. Thus, this study reports U.S. national norms for both Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI) among hospitalized adults based on age, biological sex, and race.

METHODS

A retrospective observational cohort study using data from the Agency of Healthcare Research and Quality U.S. National Inpatient Sample database for 2017. Patient data were extracted from 7 159 694 inpatient adults, and analyses were focused on individuals older than 45 years, yielding 4 370 225 patients. International Classification of Diseases, 10th Edition, diagnostic codes were used to calculate CCI and ECI scores. These scores were then weighted for the U.S. national population.

RESULTS

The weighted mean CCI was 1.22 (95% confidence interval [CI]: 1.22, 1.22), and the weighted mean ECI was 2.76 (95% CI: 2.76, 2.76). Both indexes had increasing average scores with increasing age, independent of sex and race (all p values < .001).

CONCLUSION

For the first time, U.S. national norms for the CCI and ECI are reported for adult inpatients. The norms can serve as a reference tool for determining if clinical and research populations have greater or lesser comorbidity burden than typical hospitalized adults in the United States for their age, sex, and race.

Morbidity and Mortality in Non-Obese Compared to Different Classes of Obesity in Patients Undergoing Transtibial Amputations

This study assesses the effect of obesity classes on outcomes and inpatient-hospital-cost compared to non-obese individuals undergoing below-knee amputations (BKAs). Retrospective matched-case controlled study performed on data from NIS Database. We identified three groups: N-Ob (BMI < 29.9 kg/m2; n = 3104), Ob-I/II (BMI: 30 to 39.9 kg/m2; n = 3107), and Ob-III (BMI > 40; n = 3092); matched for gender, comorbidities, tobacco use and elective vs. emergent surgery. Differences in morbidity, mortality, hospital length of stay (LOS), and total inpatient cost were analyzed. Blood loss anemia was more common in Ob-III compared to Ob-I/II patients (OR = 1.2; 95% CI = 1.1−1.4); blood transfusions were less commonly required in Ob-I/II (OR = 0.8; 95% CI = 0.7−0.9) comparatively; Ob-I/II encountered pneumonia less frequently (OR = 0.9; 95% CI = 0.4−0.9), whereas myocardial infarction was more frequent (OR = 7.0; 95% CI = 2.1−23.6) compared to N-Ob patients. Acute renal failure is more frequent in Ob-I/II (OR = 1.2; 95% CI = 1.0−1.3) and Ob-III (OR = 1.8; 95% CI = 1.6−1.9) compared to the N-Ob cohort. LOS was higher in N-Ob (13.1 ± 12.8 days) and Ob-III (13.5 ± 12.4 d) compared to Ob-I/II cohort (11.8 ± 10.1 d; p < 0.001). Mortality was 2.8%, 1.4%, and 2.9% (p < 0.001) for N-Ob, Ob-I/II, and Ob-III, respectively. Hospital charges were $22,025 higher in the Ob-III cohort. Ob-I/II is protective against peri-operative complications and death, whereas hospital cost is substantially higher in Ob-III patients undergoing BKAs.

Epidemiology and Outcomes of Hospitalizations Due to Hepatocellular Carcinoma

Background Hepatocellular Carcinoma (HCC) is a severe complication of cirrhosis and the incidence of HCC has been increasing in the United States (US). We aim to describe the trends, characteristics, and outcomes of hospitalizations due to HCC across the last decade. Methods We derived a study cohort from the Nationwide Inpatient Sample (NIS) for the years 2008-2017. Adult hospitalizations due to HCC were identified using the International Classification of Diseases (9th/10th Editions) Clinical Modification diagnosis codes (ICD-9-CM/ICD-10-CM). Comorbidities were also identified by ICD-9/10-CM codes and Elixhauser Comorbidity Software (Agency for Healthcare Research and Quality, Rockville, Maryland, US). Our primary outcomes were in-hospital mortality and discharge to the facility. We then utilized the Cochran-Armitage trend test and multivariable survey logistic regression models to analyze the trends, outcomes, and predictors. Results A total of 155,436 adult hospitalizations occurred due to HCC from 2008-2017. The number of hospitalizations with HCC decreased from 16,754 in 2008 to 14,715 in 2017. Additionally, trends of in-hospital mortality declined over the study period but discharge to facilities remained stable. Furthermore, in multivariable regression analysis, predictors of increased mortality in HCC patients were advanced age (OR 1.1; 95%CI 1.0-1.2; p< 0.0001), African American (OR 1.3; 95%CI 1.1-1.4;p< 0.001), Rural/ non-teaching hospitals (OR 2.7; 95%CI 2.4-3.3; p< 0.001), uninsured (OR 1.9; CI 1.6-2.2; p< 0.0001) and complications like septicemia and pneumonia as well as comorbidities such as hypertension, diabetes mellitus, and renal failure. We observed similar trends in discharge to facilities. Conclusions In this nationally representative study, we observed a decrease in hospitalizations of patients with HCC along with in-hospital mortality; however, discharge to facilities remained stable over the last decade. We also identified multiple predictors significantly associated with increased mortality, some of which are potentially modifiable and can be points of interest for future studies.

Postoperative Hospital Outcomes of Elective Surgery for Nonmalignant Colorectal Polyps: Does the Burden Justify the Indication?

INTRODUCTION

Despite the increasing availability of advanced endoscopic resections and its favorable safety profile, surgery for nonmalignant colorectal polyps has continually increased. We sought to evaluate readmission rates and outcomes of elective surgery for nonmalignant colorectal polyps on a national level in the United States.

METHODS

The Nationwide Readmissions Database (2010-2014 [International Classification of Diseases, Ninth Revision] and 2016-2018 [International Classification of Diseases, 10th Revision]) was used to identify all adult subjects (age ≥18 years) who underwent elective surgical resection of nonmalignant colorectal polyps. Multivariable analyses were performed for predictors of postoperative morbidity and 30-day readmission.

RESULTS

Elective surgery for nonmalignant colorectal polyps was performed in 108,468 subjects from 2010 to 2014 and in 54,956 subjects from 2016 to 2018, most of whom were laparoscopic. Postoperative morbidity and 30-day readmission rates were 20.5% and 8.5% from 2010 to 2014, and 13.0% and 7.6% from 2016 to 2018, respectively. Index admission mortality rates were 0.3-0.4%; mortality rates were higher in those with postoperative morbidity. Multivariable analyses revealed that male sex, ≥3 comorbidities, insurance status, and open surgery predicted an increased risk of both postoperative morbidity and 30-day readmission. In addition, postoperative morbidity (2010-2014 [odds ratio 1.58; 95% confidence interval 1.44-1.74] and 2016-2018 [odds ratio 1.55; 95% confidence interval 1.37-1.75]) predicted early readmission.

DISCUSSION

In this investigation of national practices, elective surgery for nonmalignant colorectal polyps remains common. There is considerable risk of adverse postoperative outcomes, which highlights the importance of increasing awareness of the range of endoscopic resections and referring subjects to expert endoscopy centers.

Race, ethnicity, and other sociodemographic characteristics of patients with hospital admission for migraine in the United States

BACKGROUND

Despite the growing awareness across the general population, migraine is often underdiagnosed and undertreated in socially and economically marginalized groups. The present study aimed to investigate the differential effects of race and income on other sociodemographic data and hospital length of stay in patients admitted to hospital with a primary diagnosis of migraine headache.

METHODS

We utilized the Nationwide Inpatient Sample (NIS) database to identify patients admitted to the hospital from 2004 to 2017 with primary diagnosis of migraine. Information on demographic and length of stay data was obtained. Only patients older than 18 years were selected and age outliers were excluded. Race groups were identified as "White", "Black", "Asian or Pacific Islander", "Native American", or "Other ethnic group", as originally reported in the NIS database. Income was identified as the estimated median household income of residents in the patient's ZIP Code.

RESULTS

A total of 106,761,737 valid cases were identified. After applying our case inclusion criteria, only 61453 (median age= 42 years, range= 18-78 years) were included. Patients identified as "Black", "Hispanic" or "Native Americans" were more likely to have lower household income (p < 0.001), whereas higher income was found for the patients identified as "White"", even when men and women were considered separately (p < 0.001). No effects of race and/or household income was found on the length of stay in hospital.

IMPLICATIONS

The occurrence of migraine diagnosis on hospital admission in the USA can be impacted by dramatic culturally driven patient-clinician communication differences between ethnic groups.

Effect of comorbidities on ischemic stroke mortality: An analysis of the National Inpatient Sample (NIS) Database

Background

Stroke risk has been attributed to many pathological and behavioral conditions. Various modifiable and non-modifiable risk factors have been recognized and found consistent throughout epidemiological studies. Herein, we investigate the effect of comorbidities seen with patient's suffering from ischemic stroke and its effect on in-hospital mortality.

Methods

We identified patients >18 year old in the National Inpatient Sample database with diseases of interest utilizing the tenth International Classification of Disease 10 diagnostic codes from the years 2016 to 2018. Interval data were analyzed using one-way ANOVA. Post hoc analysis was performed using Bonferroni correction methods. To determine independent predictors of in-hospital mortality, odds ratios were calculated using binary logistic regression for each comorbidity. Descriptive and numerical statistics, imputation, and logistic regression were calculated using SPSS software version 25.

Results

Patients hospitalized with ischemic stroke were found to have the following comorbidities: atrial fibrillation (7.5%), carotid artery stenosis (1.1%), diabetes mellitus type 2 (11.4%), congestive heart failure (CHF) (7.5%), essential hypertension (21.2%), and ischemic heart disease (IHD) (2.3%). In-hospital mortality rates were higher in patients hospitalized with ischemic stroke and concomitant IHD (28.2%, P < 0.001). Hospital length of stay was longest in patients with concomitant CHF (5.96 days, P < 0.001). Similarly, patients with CHF accrued the greatest in-hospital costs (69,174 USD, P < 0.001).

Conclusion

Patients hospitalized from ischemic stroke suffered from the coexistence of other comorbidities. Of the comorbidities studied, IHD was identified as having the most significant impact on in-hospital mortality.

Fix it while you can … Mortality after umbilical hernia repair in cirrhotic patients

BACKGROUND

We hypothesize that patients with compensated cirrhosis undergoing elective UHR have an improved mortality compared to those undergoing emergent UHR.

METHOD

The NIS was queried for patients undergoing UHR by CPT code, and ICD-10 codes were used to define separate patient categories of non-cirrhosis (NC), compensated cirrhosis (CC) and decompensated cirrhosis (DC).

RESULTS

A total of 32,526 patients underwent UHR, 97% no cirrhosis, 1.1% compensated cirrhosis, 1.7% decompensated cirrhosis. On logistic regression, cirrhosis was found to be independently associated with mortality (OR 2.841, CI 2.14-3.77). On subset analysis of only cirrhosis patients, elective repair was found to be protective from mortality (OR 0.361, CI 0.15-0.87, p = 0.02).

CONCLUSIONS

In this retrospective review, cirrhosis as well as emergent UHR in cirrhotic patients were independently associated with mortality. More specifically, electively (rather than emergently) repairing an umbilical hernia in cirrhotic patients was independently associated with a 64% reduction in mortality.