The definition of a prolonged intensive care unit stay for spontaneous intracerebral hemorrhage patients: an application with national health insurance research database

Timely goals of care documentation in patients with frailty in the COVID-19 era: a retrospective multi-site study

BACKGROUND

Older frail patients are more likely to have timely goals of care (GOC) documentation than non-frail patients.

AIMS

To investigate whether timely documentation of GOC within 72 h differed in the context of the COVID-19 pandemic (2020), compared with the pre-COVID-19 era (2019) for older frail patients.

METHODS

Multi-site retrospective cohort study was conducted in two public hospitals where all consecutive frail adult patients aged ≥65 years were admitted under medical units for at least 24 h between 1 March 31 and October in 2019 and between 1 March and 31 October 2020 were included. The GOC was derived from electronic records. Frailty status was derived from hospital coding data using hospital frailty risk score (frail ≥5). The primary outcome was the documentation of GOC within 72 h of hospital admission. Secondary outcomes included hospital mortality, rapid response call, intensive care unit admission, prolonged hospital length of stay (≥10 days) and time to the documentation of GOC.

RESULTS

The study population comprised 2021 frail patients admitted in 2019 and 1849 admitted in 2020, aged 81.2 and 90.9 years respectively. The proportion of patients with timely GOC was lower in 2020, than 2019 (48.3% (893/1849) vs 54.9% (1109/2021); P = 0.021). After adjusting for confounding factors, patients in 2020 were less likely to receive timely GOC (odds ratio = 0.77; 95% confidence interval (CI) 0.68-0.88). Overall time to GOC documentation was longer in 2020 (hazard ratio = 0.86; 95% CI 0.80-0.93).

CONCLUSION

Timely GOC documentation occurred less frequently in frail patients during the COVID-19 pandemic than in the pre-COVID-19 era.

Systematic Review of Resource Use and Costs in the Hospital Management of Intracerebral Hemorrhage

BACKGROUND

While clinical guidelines provide a framework for hospital management of spontaneous intracerebral hemorrhage (ICH), variation in the resource use and costs of these services exists. We sought to perform a systematic literature review to assess the evidence on hospital resource use and costs associated with management of adult patients with ICH, as well as identify factors that impact variation in such hospital resource use and costs, regarding clinical characteristics and delivery of services.

METHODS

A systematic literature review was performed using PubMed, Cochrane Central Register of Controlled Trials, and Ovid MEDLINE(R) 1946 to present. Articles were assessed against inclusion and exclusion criteria. Study design, ICH sample size, population, setting, objective, hospital characteristics, hospital resource use and cost data, and main study findings were abstracted.

RESULTS

In total, 43 studies met the inclusion criteria. Pertinent clinical characteristics that increased hospital resource use included presence of comorbidities and baseline ICH severity. Aspects of service delivery that greatly impacted hospital resource consumption included intensive care unit length of stay and performance of surgical procedures and intensive care procedures.

CONCLUSIONS

Hospital resource use and costs for patients with ICH were high and differed widely across studies. Making concrete conclusions on hospital resources and costs for ICH care was constrained, given methodologic and patient variation in the studies. Future research should evaluate the long-term cost-effectiveness of ICH treatment interventions and use specific economic evaluation guidelines and common data elements to mitigate study variation.

Diseases That Occur Prior to Spontaneous Intracerebral Hemorrhage: Identification of Predisposing and Risk Factors Using Lag Sequential Analysis

Spontaneous intracerebral hemorrhage (sICH) has many predisposing/risk factors. Lag sequential analysis (LSA) is a method of analyzing sequential patterns and their associations within categorical data in different system states. The results of this study will assist in preventing sICH and improving the patient outcome after sICH. The correlations between a first sICH and previous clinic visits were examined using LSA with data obtained from the Taiwan National Health Insurance Research Database (NHIRD). In this study, LSA was employed to examine the data in the Taiwan NHIRD in order to identify predisposing and risk factors related to sICH, and the results increased our knowledge of the temporal relationships between diseases. This study employed LSA to identify predisposing/risk factors prior to the first occurrence of sICH using a healthcare administrative database in Taiwan. The data were managed using the clinical classification software (CCS). All cases of traumatic ICH were excluded. Ten disease groups were identified using CCS. Hypertension and dizziness/vertigo were identified as two important predisposing/risk factors for sICH, and early treatment of hypertension resulted in a greater survival rate. Five disease groups were found to have occurred prior to other diseases and affected mostly the elderly, resulting in subsequent sICH. The results of this study also showed that nutritional status and tooth health were highly associated with the occurrence of sICH owing to a poor state of the digestive system. In conclusion, there are many diseases that influence the risk of a subsequent sICH. This study demonstrated that LSA is a very useful tool for future study of healthcare administrative databases.

Is it time to reconsider the administration of thiamine alone or in combination with vitamin C in critically ill patients? A meta-analysis of clinical trial studies

Background

Although the effect of thiamine alone or in combination with vitamin C has been studied in multiple trials (RCT and interventional studies), their results are inconsistent. This meta-analysis aimed to assess impact of thiamine administration alone, thiamine in combination with vitamin C, and co-administration of low-dose hydrocortisone, vitamin C and thiamine (HVT) on clinical outcomes in critically ill patients.

Methods and materials

After electronic searches on PubMed, Scopus, Cochrane Library, and Web of Science databases, initially 3367 papers were found, and 20 interventional studies were included in our analysis. We assessed the risk-difference between treatment and control (standard treatment) groups by pooling available data on ICU length of stay, number of ventilator free days, mortality, and changes in Sequential Organ Failure Assessment (SOFA) scores.

Results

The results of present studies revealed no significant effect of thiamine in combination with vitamin C, and HVT on number of free days of ventilation. Thiamine alone supplementation was associated with high mortality percentage (WMD: 5.17%; 95% CI: 2.67, 7.67). Thiamine in combination with vitamin C had no significant impact on mortality rate. In contrast, HVT could decrease mortality rate (WMD: − 7.23%; 95% CI: − 10.31, − 4.16; I-square: 0.0%). There was no significant effect of thiamine alone, co-administration of thiamine and vitamin C, and HVT on ICU length of stay. The results of the meta-analysis showed that thiamine alone and HVT supplementation had no significant effect on SOFA score. Interestingly, co-supplementation of thiamine and vitamin C had a significant decreasing effect on SOFA score (WMD: − 0.73; 95% CI: − 1.29, − 0.17; I-square: 0.0%).

Conclusion

In contrast to HVT, thiamine supplementation alone was associated with increased mortality rate in ICU. However, co-supplementation of thiamine and vitamin C had a significant decreasing effect on SOFA score.

Thiamine, co-supplementation of thiamine and vitamin C and co-administration of hydrocortisone, vitamin C and thiamine (HVT) had no significant effect on free days of ventilation and ICU length of stay.

HVT could decrease and thiamine supplementation could increase mortality rate in ICU.

Co-supplementation of thiamine and vitamin C could decrease SOFA score.

Correlation of Serum Albumin Level to Lung Ultrasound Score and Its Role as Predictors of Outcome in Acute Respiratory Distress Syndrome Patients: A Prospective Observational Study

Background

There is ambiguity in the literature regarding hypoalbuminemia as a cause of extravascular lung water and acute respiratory distress syndrome (ARDS) outcomes. The aim of the study was to determine if low serum albumin on admission leads to lung deaeration and higher lung ultrasound score (LUSS) in ARDS patients. Patients and Methods. It was a prospective observational study in which 110 ARDS patients aged between 18 and 70 years were recruited. Serum albumin level and lung ultrasound score were assessed on the day of ICU admission. Length of ICU stay and hospital mortality were recorded.

Results

The mean and standard deviation of serum albumin level in mild, moderate, and severe ARDS was 2.92 ± 0.65 g/dL, 2.91 ± 0.77 g/dL, and 3.21 ± 0.85 g/dL, respectively. Albumin level was not correlated to the global LUSS (Pearson correlation r −0.006, p=0.949) and basal LUSS (r −0.066, p=0.513). The cut-off value of albumin for predicting a prolonged length of ICU stay (≥10 days) in ARDS patients was <3.25 g/dL with AUC 0.623, p < 0.05, sensitivity of 86.67%, specificity of 45.45%, and 95% confidence interval (CI) [0.513–0.732], and on multivariate analysis it increased the odds of prolonged ICU stay by 8.9 times (Hosmer and Lemeshow p value 0.810, 95% CI [2.760–28.72]). Serum albumin at admission was not a predictor of mortality. LUSS on the day of admission was not useful to predict either a prolonged length of ICU stay or mortality. Basal LUSS contributed about 56% of the global LUSS in mild and moderate ARDS, and 53% in severe ARDS.

Conclusion

Serum albumin level was unrelated to LUSS on admission in ARDS patients. Albumin level <3.25 g/dL increased the chances of a prolonged length of ICU stay (≥10 days) but was not associated with an increase in mortality. LUSS on the day of admission could not predict either a prolonged length of ICU stay or mortality. This trial is registered with CTRI/2019/11/021857.

Frailty status, timely goals of care documentation and clinical outcomes in older hospitalised medical patients

BACKGROUND

Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care (GOC) documentation is vital to avoid futile/unwarranted interventions in the event of deterioration.

AIMS

To investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients.

METHODS

This was a single-centre retrospective study of all medical patients aged ≥80 years admitted to the acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using the Hospital Frailty Risk Score (HFRS) derived from hospital coding data. Primary outcome compared proportions of timely GOC within 72-h between frail (HFRS ≥ 5) and non-frail (HFRS < 5) patients. Exploratory secondary outcomes included in-hospital mortality, rapid response calls (RRC), prolonged length of stay (LOS) and 28-day readmission rates.

RESULTS

Of the 1118 admitted patients, 529 (47.3%) were frail. Timely GOC occurred in 50% (559/1118), more commonly in frail patients (283/529, 53.5%) than non-frail patients (276/589, 46.9%), P = 0.027. Frailty was positively associated with timely GOC independent of age and gender (odds ratio = 1.28; 95% confidence interval = 1.01-163; P = 0.041). In univariable analyses, timely GOC was associated with greater in-hospital mortality, RRC, and hospital LOS in both frail and non-frail patients (all P < 0.05) and greater 28-day readmissions only among frail patients (P = 0.028). Multivariable regression demonstrated that timely GOC was associated only with in-hospital mortality in both frail and non-frail patients, independent of age and gender.

CONCLUSION

Older frail hospitalised patients were more likely to have timely GOC than older non-frail patients. Timely GOC in such patients may avoid burdensome treatments.

Correlation of Oxygenation and Radiographic Assessment of Lung Edema (RALE) Score to Lung Ultrasound Score (LUS) in Acute Respiratory Distress Syndrome (ARDS) Patients in the Intensive Care Unit

Background

Lung ultrasound score (LUS) as well as radiographic assessment of lung edema (RALE) score as calculated from chest radiography (CXR) have been applied to assess Acute Respiratory Distress Syndrome (ARDS) severity. CXRs, which are frequently performed in ARDS patients, pose a greater risk of radiation exposure to patients and health care staff.

Aims and objectives

The aim of the study was to evaluate if LUS had a better correlation to oxygenation (PaO₂/FiO₂) compared with the RALE score in ARDS patients. We also aimed to analyse if there was a correlation between RALE score and LUS. We wanted to determine the LUS and RALE score cut-off, which could predict a prolonged length of intensive care unit (ICU) stay (≥10 days) and survival.

Methods

Thirty-seven patients aged above 18 years with ARDS as per Berlin definition and admitted to the ICU were included in the study. It was a retrospective study done over a period of 11 months. On the day of admission to ICU, the global and basal LUS, global and basal RALE score, and PaO₂ /FiO₂ were recorded. Outcome and days of ICU stay were noted.

Results

Global LUS score and PaO₂/FiO₂ showed the best negative correlation (r = –0.491), which was significant (p = 0.002), followed by global RALE score and PaO₂/FiO₂ (r = –0.422, p = 0.009). Basal LUS and PaO₂/FiO₂ also had moderate negative correlation (r = –0.334, p = 0.043) followed by basal RALE score and PaO₂/FiO₂ (r = –0.34, p = 0.039). Global RALE score and global LUS did not show a significant correlation. Similarly, there was no significant correlation between basal RALE score and basal LUS. Global and basal LUS as well as global and basal RALE score were not beneficial in predicting either a prolonged length of ICU stay or survival as the area under curve was low.

Conclusion

In ARDS patients, global LUS had the best correlation to oxygenation (PaO₂/FiO₂), followed by global RALE score. Basal LUS and basal RALE score also had moderate correlation to oxygenation. However, there was no significant correlation between global LUS and global RALE score as well as between basal LUS and basal RALE score. Global and basal LUS as well as global and basal RALE scores were not able to predict a prolonged ICU stay or survival in ARDS patients.

Early Determinants of Neurocritical Care Unit Length of Stay in Patients with Spontaneous Intracerebral Hemorrhage

BACKGROUND

The present study considers patients with spontaneous intracerebral hemorrhage (ICH) admitted to the neurocritical care unit (NCCU) through the Emergency Department (ED). It aims to identify patient-specific clinical variables that can be assessed on presentation and that are associated with prolonged NCCU length of stay (LOS).

METHODS

A cross-sectional, single-center, retrospective analysis of ICH patients directly admitted from the ED to the NCCU over an 8-year period was performed. Patients' demographics, clinical exam characteristics, serum laboratory values, intubation status, and neurosurgical procedures at presentation were recorded. Head computed tomography scans obtained on presentation were reviewed. LOS was calculated based on the number of midnights spent in the NCCU. Prolonged LOS was determined using a change point analysis, adopting the method of Taylor which utilizes CUMSUM charts and bootstrap analysis. A decision tree model was trained and validated to identify reliable variables associated with prolonged LOS.

RESULTS

Two hundred and five patients with ICH were analyzed. Prolonged LOS was calculated to be a stay that exceeds 8 days; 68 patients (33%) had a prolonged LOS in NCCU. Median LOS did not differ between survivors and patients who died in hospital. Clinical variables explored through the decision tree model were intubation status, neurosurgical intervention (EVD, decompression or evacuation within 24 h from presentation), and components of the ICH score: age, GCS, hematoma volume, the presence of intraventricular hemorrhage (IVH), and infratentorial location. The model accuracy was 0.8 and AUC was 0.83 (95% CI 0.78-0.89).

CONCLUSION

We propose an ICH-LOS model based on neurosurgical intervention, intubation status and GCS at presentation to predict prolonged LOS in the NCCU in patients with ICH. This simple clinical tool, if prospectively validated, could help with medical planning, contribute to patient care-directed conversations, assist in optimizing hospital resource utilization, and, more importantly, motivating patient-specific interventions aimed at optimizing outcomes and decreasing LOS.

Adverse outcomes of delayed intensive care unit

OBJECTIVE

To examine the impact of delayed transfer from the emergency room into the intensive care unit on the length of intensive care unit stay and death.

METHODS

This prospective, cohort study performed in a tertiary academic hospital obtained data from 1913 patients admitted to the emergency room with a documented request for admission into the intensive care unit. The patients admitted directly into the medical-surgical intensive care unit (n = 209) were categorized into tertiles according to their waiting time for intensive care unit admission (Group 1: < 637 min, Group 2: 637 to 1602 min, and Group 3: > 1602 min). Patients who stayed in the intensive care unit for longer than 3.2 days (median time of intensive care unit length of stay of all patients) were considered as having a prolonged intensive care unit stay.

RESULTS

A total of 6,176 patients were treated in the emergency room during the study period, among whom 1,913 (31%) required a bed in the intensive care unit. The median length of stay in the emergency room was 17 hours [9 to 33 hours]. Hospitalization for infection/sepsis was an independent predictor of prolonged intensive care unit stay (OR 2.75 95%CI 1.38 - 5.48, p = 0.004), but waiting time for intensive care unit admission was not. The mortality rate was higher in Group 3 (38%) than in Group 1 (31%) but the difference was not statistically significant.

CONCLUSION

Delayed admission into the intensive care unit from the emergency room did not result in an increased intensive care unit stay or mortality.

Brainstem hemorrhage is uncommon and is associated with high morbidity, mortality, and prolonged hospitalization

OBJECTIVE

To determine the frequency, risk factors, and outcomes of patients with brainstem hemorrhage in stroke center at King Abdulaziz Medical City, Riyadh.

METHODS

A retrospective, observational cohort study including all patients with brainstem hemorrhage from January 2014 to December 2017. The clinical presentation, location of hemorrhage, complications and clinical outcomes were analyzed.

RESULTS

Of 1921 stroke patients, 219 had hemorrhagic stroke (11.4%), of whom only 10 (4.6%) had brainstem hemorrhage, comprising 0.5% of all stroke patients. All patients were men; mean age was 58.5 years. Most frequent presenting symptoms were headache (70%), unilateral weakness (60%), and loss of consciousness (50%). All patients had hemorrhage in pons, 5 had concomitant cerebellar hemorrhage (50%), one had medullary hemorrhage, and one midbrain hemorrhage (10% each). Mean ICU stay was 17 days; mean hospital stay was 58 days. At the time of discharge, three (30%) had mRS of 0-2, 5 (50%) had mRS of 3-5, whereas 2 (20%) had died. Glasgow coma scale (GCS) of >8 at presentation was associated with a good outcome at three months (p=0.03). Presentation within six hours of symptom onset (p=0.233), hypertension on presentation (p=0.233), and age less than 60 years (p=0.065) did not affect discharge outcomes.

CONCLUSION

Brainstem hemorrhage occurred in 0.5% of all stroke patients. It was associated with high morbidity and mortality. Low Glasgow Coma Scale at presentation was associated with poor outcomes.

Determining the Cost and Length of Stay at Intensive Care Units and the Factors Influencing Them in a Teaching Hospital in Malaysia

OBJECTIVES

Escalating healthcare costs calls for the efficiency of health services, especially in the intensive care unit (ICU) where the bulk of resources are used. This study aims to identify the length of stay (LOS) and cost of care at ICUs, which are proxy indicators of efficiency and the factors determining them.

METHODS

A cross-sectional study of patients requiring ICU admissions in a teaching hospital in Malaysia from 2013 to 2015 was conducted. The cost at the ICU was estimated using the step down approach. Factors that determined the cost and LOS at the ICU were also explored by using multivariate regression analysis.

RESULTS

Each day of stay cost $427 (USD) at the pediatric intensive care unit and $1324 at the general intensive care unit. The mean LOS at the ICU was 5.7 days (standard deviation [SD]: 8.4) with a median of 4 days (95% confidence interval [CI] 1-16.7 days). Average cost of care at the ICU per episode of care was $5473 (SD $6499), and the median was $3463. ICU patients spent 29.3% of the total stay and 47.2% of the cost at ICU units. Upon multivariate regression analysis, severity, case base-group, and type of ICU that the patient was admitted to were associated with the cost and LOS at ICU.

CONCLUSIONS

Compared with critical care practices in hospitals from more developed nations, a Malaysian teaching hospital required a longer length of ICU stay. Hence, implementations of strategies that can reduce the length of stay and hospital costs without compromising healthcare quality are required.

Exploration of Medical Trajectories of Stroke Patients Based on Group-Based Trajectory Modeling

A high mortality rate is an issue with acute cerebrovascular disease (ACVD), as it often leads to a high medical expenditure, and in particular to high costs of treatment for emergency medical conditions and critical care. In this study, we used group-based trajectory modeling (GBTM) to study the characteristics of various groups of patients hospitalized with ACVD. In this research, the patient data were derived from the 1 million sampled cases in the National Health Insurance Research Database (NHIRD) in Taiwan. Cases who had been admitted to hospitals fewer than four times or more than eight times were excluded. Characteristics of the ACVD patients were collected, including age, mortality rate, medical expenditure, and length of hospital stay for each admission. We then performed GBTM to examine hospitalization patterns in patients who had been hospitalized more than four times and fewer than or equal to eight times. The patients were divided into three groups according to medical expenditure: high, medium, and low groups, split at the 33rd and 66th percentiles. After exclusion of unqualified patients, a total of 27,264 cases (male/female = 15,972/11,392) were included. Analysis of the characteristics of the ACVD patients showed that there were significant differences between the two gender groups in terms of age, mortality rate, medical expenditure, and total length of hospital stay. In addition, the data were compared between two admissions, which included interval, outpatient department (OPD) visit after discharge, OPD visit after hospital discharge, and OPD cost. Finally, the differences in medical expenditure between genders and between patients with different types of stroke-ischemic stroke, spontaneous intracerebral hemorrhage (sICH), and subarachnoid hemorrhage (SAH)-were examined using GBTM. Overall, this study employed GBTM to examine the trends in medical expenditure for different groups of stroke patients at different admissions, and some important results were obtained. Our results demonstrated that the time interval between subsequent hospitalizations decreased in the ACVD patients, and there were significant differences between genders and between patients with different types of stroke. It is often difficult to decide when the time has been reached at which further treatment will not improve the condition of ACVD patients, and the findings of our study may be used as a reference for assessing outcomes and quality of care for stroke patients. Because of the characteristics of NHIRD, this study had some limitations; for example, the number of cases for some diseases was not sufficient for effective statistical analysis.

Differences in Spontaneous Intracerebral Hemorrhage Cases between Urban and Rural Regions of Taiwan: Big Data Analytics of Government Open Data

This study evaluated the differences in spontaneous intracerebral hemorrhage (sICH) between rural and urban areas of Taiwan with big data analysis. We used big data analytics and visualization tools to examine government open data, which included the residents’ health medical administrative data, economic status, educational status, and relevant information. The study subjects included sICH patients of Taipei region (29,741 cases) and Eastern Taiwan (4565 cases). The incidence of sICH per 100,000 population per year in Eastern Taiwan (71.3 cases) was significantly higher than that of the Taipei region (42.3 cases). The mean coverage area per hospital in Eastern Taiwan (452.4 km²) was significantly larger than the Taipei region (24 km²). The residents educational level in the Taipei region was significantly higher than that in Eastern Taiwan. The mean hospital length of stay in the Taipei region (17.9 days) was significantly greater than that in Eastern Taiwan (16.3 days) (p < 0.001). There were no significant differences in other medical profiles between two areas. Distance and educational barriers were two possible reasons for the higher incidence of sICH in the rural area of Eastern Taiwan. Further studies are necessary in order to understand these phenomena in greater depth.

Does the Short-Term Effect of Air Pollution Influence the Incidence of Spontaneous Intracerebral Hemorrhage in Different Patient Groups? Big Data Analysis in Taiwan

Spontaneous intracerebral hemorrhage (sICH) has a high mortality rate. Research has demonstrated that the occurrence of sICH is related to air pollution. This study used big data analysis to explore the impact of air pollution on the risk of sICH in patients of differing age and geographic location. 39,053 cases were included in this study; 14,041 in the Taipei region (Taipei City and New Taipei City), 5537 in Taoyuan City, 7654 in Taichung City, 4739 in Tainan City, and 7082 in Kaohsiung City. The results of correlation analysis indicated that there were two pollutants groups, the CO and NO₂ group and the PM_2.5 and PM₁₀ group. Furthermore, variations in the correlations of sICH with air pollutants were identified in different age groups. The co-factors of the influence of air pollutants in the different age groups were explored using regression analysis. This study integrated Taiwan National Health Insurance data and air pollution data to explore the risk factors of sICH using big data analytics. We found that PM_2.5 and PM₁₀ are very important risk factors for sICH, and age is an important modulating factor that allows air pollutants to influence the incidence of sICH.

Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium

PURPOSE

We investigated the impact of delirium on illness severity, psychological state, and memory in acute respiratory distress syndrome patients with very long ICU stay.

MATERIALS AND METHODS

Prospective cohort study in the medical-surgical ICUs of 2 teaching hospitals. Very long ICU stay (>75days) and prolonged delirium (≥40days) thresholds were determined by ROC analysis. Subjects were ≥18years, full-code, and provided informed consent. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation IV, Simplified Acute Physiology Score-3, and Sequential Organ Failure Assessment scores. Psychological impact was assessed using the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, and the 14-question Post-Traumatic Stress Syndrome (PTSS-14). Memory was assessed using the ICU Memory Tool survey.

RESULTS

181 subjects were included. Illness severity did not correlate with delirium duration. On logistic regression, only PTSS-14<49 correlated with delirium (p=0.001; 95% CI 1.011, 1.041). 49% remembered their ICU stay clearly. 47% had delusional memories, 50% reported intrusive memories, and 44% reported unexplained feelings of panic or apprehension.

CONCLUSION

Delirium was associated with memory impairment and PTSS-14 scores suggestive of PTSD, but not illness severity.

Validation of a novel claims-based stroke severity index in patients with intracerebral hemorrhage

BACKGROUND

Stroke severity is an important outcome predictor for intracerebral hemorrhage (ICH) but is typically unavailable in administrative claims data. We validated a claims-based stroke severity index (SSI) in patients with ICH in Taiwan.

METHODS

Consecutive ICH patients from hospital-based stroke registries were linked with a nationwide claims database. Stroke severity, assessed using the National Institutes of Health Stroke Scale (NIHSS), and functional outcomes, assessed using the modified Rankin Scale (mRS), were obtained from the registries. The SSI was calculated based on billing codes in each patient's claims. We assessed two types of criterion-related validity (concurrent validity and predictive validity) by correlating the SSI with the NIHSS and the mRS. Logistic regression models with or without stroke severity as a continuous covariate were fitted to predict mortality at 3, 6, and 12 months.

RESULTS

The concurrent validity of the SSI was established by its significant correlation with the admission NIHSS (r = 0.731; 95% confidence interval [CI], 0.705-0.755), and the predictive validity was verified by its significant correlations with the 3-month (r = 0.696; 95% CI, 0.665-0.724), 6-month (r = 0.685; 95% CI, 0.653-0.715) and 1-year (r = 0.664; 95% CI, 0.622-0.702) mRS. Mortality models with NIHSS had the highest area under the receiver operating characteristic curve, followed by models with SSI and models without any marker of stroke severity.

CONCLUSIONS

The SSI appears to be a valid proxy for the NIHSS and an effective adjustment for stroke severity in studies of ICH outcome with administrative claims data.

Defining Prolonged Length of Acute Care Stay for Surgically and Conservatively Treated Patients with Spontaneous Intracerebral Hemorrhage: A Population-Based Analysis

Background. The definition of prolonged length of stay (LOS) during acute care remains unclear among surgically and conservatively treated patients with intracerebral hemorrhage (ICH). Methods. Using a population-based quality assessment registry, we calculated change points in LOS for surgically and conservatively treated patients with ICH. The influence of comorbidities, baseline characteristics at admission, and in-hospital complications on prolonged LOS was evaluated in a multivariate model. Results. Overall, 13272 patients with ICH were included in the analysis. Surgical therapy of the hematoma was documented in 1405 (10.6%) patients. Change points for LOS were 22 days (CI: 8, 22; CL 98%) for surgically treated patients and 16 days (CI: 16, 16; CL: 99%) for conservatively treated patients. Ventilation therapy was related to prolonged LOS in surgically (OR: 2.2, 95% CI: 1.5–3.1; P < 0.001) and conservatively treated patients (OR: 2.5, 95% CI: 2.2–2.9; P < 0.001). Two or more in-hospital complications in surgical patients (OR: 2.7, 95% CI: 2.1–3.5) and ≥1 in conservative patients (OR: 3.0, 95% CI: 2.7–3.3) were predictors of prolonged LOS. Conclusion. The definition of prolonged LOS after ICH could be useful for several aspects of quality management and research. Preventing in-hospital complications could decrease the number of patients with prolonged LOS.