Demographic Disparities in the Incidence, Clinical Characteristics, and Outcome of Posterior Reversible Encephalopathy Syndrome in the United States

OBJECTIVES

To estimate age-specific, sex-specific, and race-specific incidence of posterior reversible encephalopathy syndrome (PRES) in the United States.

METHODS

We conducted a retrospective cohort study using the State Inpatient Database of Florida (2016-2019), Maryland (2016-2019), and New York (2016-2018). All new cases of PRES in adults (18 years or older) were combined with Census data to compute incidence. We evaluated the generalizability of incident estimates to the entire country using the 2016-2019 National Readmissions Database (NRD).

RESULTS

Across the study period, there were 3,716 incident hospitalizations for PRES in the selected states. The age-standardized and sex-standardized incidence of PRES was 2.7 (95% CI 2.5-2.8) cases/100,000/y. Incidence in female patients was >2 times that of male patients (3.7 vs 1.6 cases/100,000/y, p < 0.001). Incidence increased with age in both sexes (p-trend <0.001). Similar demographic distribution of first hospitalization for PRES was also noted in the entire country using the NRD. Age-standardized and sex-standardized PRES incidence in Black patients (4.2/100,000/y) was significantly greater than in Non-Hispanic White (2.7/100,000/y) and Hispanic patients (1.2/100,000/y) (p < 0.001 for pairwise comparisons).

DISCUSSION

The incidence of PRES in the United States is approximately 3/100,000/y, but incidence in female patients is >2 times that of male patients. PRES incidence is higher in Black compared with non-Hispanic White and Hispanic patients.

Age- and Sex-Specific Trends in Medical Complications After Acute Ischemic Stroke in the United States

BACKGROUND AND OBJECTIVES

To test the hypothesis that the age and sex-specific prevalence of infectious (pneumonia, sepsis, and urinary tract infection [UTI]) and noninfectious (deep venous thrombosis [DVT], pulmonary embolism [PE], acute renal failure [ARF], acute myocardial infarction [AMI], and gastrointestinal bleeding [GIB]) complications increased after acute ischemic stroke (AIS) hospitalization in the United States from 2007 to 2019.

METHODS

We conducted a serial cross-sectional study using the 2007-2019 National Inpatient Sample. Primary AIS admissions in adults (aged 18 years or older) with and without complications were identified using International Classification of Diseases codes. We quantified the age/sex-specific prevalence of complications and used negative binomial regression models to evaluate trends over time.

RESULTS

Of 5,751,601 weighted admissions, 51.4% were women. 25.1% had at least 1 complication. UTI (11.8%), ARF (10.1%), pneumonia (3.2%), and AMI (2.5%) were the most common complications, while sepsis (1.7%), GIB (1.1%), DVT (1.2%), and PE (0.5%) were the least prevalent. Marked disparity in complication risk existed by age/sex (UTI: men 18-39 years 2.1%; women 80 years or older 22.5%). Prevalence of UTI (12.9%-9.7%) and pneumonia (3.8%-2.7%) declined, but that of ARF increased by ≈3-fold (4.8%-14%) over the period 2007-2019 (all p < 0.001). AMI (1.9%-3.1%), DVT (1.0%-1.4%), and PE (0.3%-0.8%) prevalence also increased (p < 0.001), but that of sepsis and GIB remained unchanged over time. After multivariable adjustment, risk of all complications increased with increasing NIH Stroke Scale (pneumonia: prevalence rate ratio [PRR] 1.03, 95% CI 1.03-1.04, for each unit increase), but IV thrombolysis was associated with a reduced risk of all complications (pneumonia: PRR 0.80, 85% CI 0.73-0.88; AMI: PRR 0.85, 95% CI 0.78-0.92; and DVT PRR 0.87, 95% CI 0.78-0.98). Mechanical thrombectomy was associated with a reduced risk of UTI, sepsis, and ARF, but DVT and PE were more prevalent in MT hospitalizations compared with those without. All complications except UTI were associated with an increased risk of in-hospital mortality (sepsis: PRR 1.97, 95% CI 1.78-2.19).

DISCUSSION

Infectious complications declined, but noninfectious complications increased after AIS admissions in the United States in the last decade. Utilization of IV thrombolysis is associated with a reduced risk of all complications.

Abstract 240: Association of Depression Risk With Patient Experience, Healthcare Expenditure and Health Resource Utilization Among Adults With Atherosclerotic Cardiovascular Disease

Background: Approximately 20% of patients with atherosclerotic cardiovascular disease (ASCVD) suffer from depression. Currently, these two conditions are the most common causes of disability in high-income countries and projected to become so for all countries by 2030. Depression is a risk marker for ASCVD and associated with worse health outcomes. In a nationally representative US adult population, we evaluate patient experience, healthcare expenditure and resource utilization among non-depressed ASCVD patients based on their risk for depression.

Methods: The 2004-2015 Medical Expenditure Panel Survey (MEPS), a nationally representative sample was the basis for our study. We included adults ≥18 years with a diagnosis of ASCVD, ascertained by ICD9 codes and/or self-reported data and excluded those with a diagnosis of Depression, identified by ICD9 code 311. Individuals were stratified by depression risk (based on the Patient Health Questionnaire-2): Two-part econometric model was used to study cost data, and regression models for all other associations, adjusted for ASCVD risk factors.

Results: The study sample consisted of 16,136 ASCVD patients without the diagnosis of depression (aged 67 ± 10 years, 55% male), translating into 179.2 million US adults, of which 8.6% (15.5 million US adults) had a high risk for depression. Individuals with high vs. low risk for depression had higher overall and out-of-pocket healthcare expenditures ($1,200 & $353, respectively; both p < 0.001). Additionally, those with high risk had higher odds for hospitalizations [OR 1.75 (1.75, 2.32)], poor self-perceived health status [OR 4.83 (3.28, 7.12)], poor patient-provider communication scores [OR 2.44 (1.93, 3.09)], poor patient satisfaction [OR 3.33 (1.64, 6.77)], and significantly worse healthcare-related quality of life measures than those with low risk for depression (Table).

Conclusion: Among ASCVD patients without a diagnosis of depression, individuals with a greater risk for depression were more likely to report worse healthcare experience, increased resource utilization and higher healthcare spending. To enhance health outcomes and increase healthcare efficiency, more aggressive screening for depression risk to promote improved recognition and intervention are needed among this vulnerable population.

Abstract 170: Racial Disparities and Patient Reported Healthcare Experience Among Adults With Atherosclerotic Cardiovascular Disease

Background: Studies report that barriers to the relationship between patients and their healthcare providers contribute to racial disparities in healthcare experience. Although race is thought to play a major role in the disparities seen in patient report on healthcare experience, results reported by different scholars on the effect of race on patient provider communication and overall patient satisfaction has been heterogeneous. In this study, we explore the relationship between patient race/ethnicity and various domains of patient healthcare experience [patient provider communication, shared decision making and overall patient satisfaction] in a nationally representative adult US population with established atherosclerotic cardiovascular disease (ASCVD).

Methods: The study population consisted of a nationally representative sample of 8223 individuals (age ≥ 18 years) representing 21.6 million with established ASCVD (self-reported or ICD-9 diagnosis) reporting a usual source of care in the 2010-2013 pooled Medical Expenditure Panel Survey (MEPS) cohort. We developed a weighted average score for each domain of patient report on healthcare experience, using responses to questions from the CAHPS survey related to patient provider communication, shared decision making and patient overall satisfaction. We compared these scores across patient race/ethnicity.

Results: The proportion of ASCVD patients with an optimal score on all domains of patient reported experience was least among Asians (patient-provider communication 37.5%, shared decision making 36.1%, satisfaction 21.9%, p<0.05). African Americans, Asians and Hispanics were less likely to report optimal patient experience when compared to non-Hispanic whites. Adjustments for covariates yielded mixed results. However, African Americans and Asians were 20% and 39% less likely to be satisfied with their healthcare providers respectively [African Americans (Adjusted OR 0.80, 95% CI 0.67-0.97), Asians (Adjusted OR 0.61, 95% CI 0.39-0.94).

Conclusion: This study reveals a strong relationship between race and patent healthcare experience among individuals with ASCVD. Targeted policies focusing on reducing disparities and improving patient healthcare experience are needed among these vulnerable population.

Abstract 684: Principal Component Analysis Identifies Lipoprotein Subfractions Associated with Coronary Artery Calcification in a Young High Cardiometabolic Risk Population: The Baptist Employee Healthy Heart Study

Introduction: There is limited evidence relating lipoprotein subfractions or their composite measures to subclinical markers of atherosclerosis. In this study, we tested whether combinations of lipoprotein subfractions independently predict the presence of Coronary Artery Calcification (CAC) among presumably healthy people with high cardiovascular disease (CVD) risk.

Methods: Cardio IQ™ Ion Mobility lipoprotein fractionation was measured at baseline in 172 high CVD risk participants of the Baptist Employee Healthy Heart Study (BEHHS). Principal component analysis was used to check for eventual components of CVD risk. Using bootstrap techniques, we created 1000 data sets of size 5000 and analyzed results of logistic regression.

Results: Three principal components (PC) accounted for 88% variability. PC1 represented an increase in all lipoprotein measures; PC2 a decrease in HDL, large and medium LDL with an increase in VLDL and small and very small LDL; PC3 an increase in HDL, and a decrease in LDL subfractions and large IDL particles. The adjusted odds ratios for the presence of CAC were: 1.01(0.98 - 1.03) for PC1, 1.22(1.17-1.27) for PC2 and 0.90 (0.85 - 0.97) for PC3. PC2 and PC3 were associated with p-values smaller than 0.05 in 100% and 88% of all models.

Conclusion: PCA of lipoprotein subfractions identified 3 independent components of CVD risk. PC2, proxy for the “atherogenic lipoprotein phenotype”, was consistently associated with the presence of underlying coronary artery calcification. There is potential to explore how lipoprotein subfractions as determined by a safe, inexpensive blood test can be used to stratify CVD risk in younger but high risk individuals.

Abstract 109: Differences in Cardiovascular Health: Why Hispanic Women Fare Better Then Non Hispanic Women: The Baptist Health South Florida Employee Study

Background: In the United States, Hispanic females have the highest life expectancy, 87 years compared to 81years for white females, 78 years for African-American females and 81 years for Hispanic males. Other ethnic and gender discrepancies are a well addressed issue in cardiac outcomes, but almost nothing is known about the potential cofounders of this striking difference. In this study, we shed light on the variables that potentially relate to the underlying differences in cardiovascular health (CVH) using data from female employees of Baptist Health South Florida, a large nonprofit health care organization.

Methods: Female employees (7683) with complete data from an annual health fair and health risk assessment (HRA) for 2014 were included in this study. Mean age was 43 ±12 years. We compared results for 4235 Hispanic females (55.1%) to non-Hispanic females (44.9%) for 21 cardiovascular health (CVH) related characteristics, grouped into biometric measurements (12), knowledge (4) and attitudes (5). All variables were dichotomized and Fisher exact test was used to test for differences. Odds ratios are used to express importance of differences and spread of data.

Results: Hispanic females demonstrated significant advantage over non-Hispanic females in 10 of 12 CVH related measurements grouped into disease conditions and risk factors. Of note, Hispanic women were 62% more likely to have 5 or more CVH metrics. There was no difference in any of the 4 knowledge questions however, Hispanic females had healthier attitudes. They were significantly less inclined to want to increase their time of exercise, and they were also less likely to worry about their weight.

In summary, Hispanic females had better CVH related biometric and behavioral profiles in 15 of 21 variables compared to non-Hispanic females.

Conclusion: In this presumably healthy working population with equal access to health care and benefits, Hispanic females showed much better values of cardiac risk factors, accompanied with positive attitude toward life. Our findings point to potential pathways of longevity and improved CVH among Hispanic females.