Takotsubo cardiomyopathy and psychiatric illness- insight from National Inpatient Sample (NIS) and National Re-admission Database (NRD) 2016 to 2018

BACKGROUND

Emotional stress is a common precipitating cause of takotsubo cardiomyopathy (TC). Preexisting psychiatric disorder (PD) was linked to worsening outcomes in patients with TC1,2. However, there is limited data in literature to support this. This study aimed to determine the differences in outcomes in TC patients with and without PD.

METHODS

We identified all patients with a diagnosis of TC using the National Inpatient Sample (NIS) and the National Readmission Database (NRD) data from 2016 to 2018. The patients were separated into TC with PD group and TC without PD group. Multiple variable logistic regression was then performed.

RESULTS

Using NIS 2016-2018, we identified 23,220 patients with TC, and 43.11% had PD. The mean age was 66.73 ± 12.74 years, with 90.42% being female sex. The TC with PD group had a higher 30-readmission rate 1.25 (95% CI:1.06-1.47), Cardiogenic shock [aOR = 7.3 (95%CI 3.97-13.6), Mechanical ventilation [aOR = 4.2 (95%CI 2.4-7.5), Cardiac arrest [aOR = 2.6 (95%CI 1.1-6.3), than TC without PD group.

CONCLUSION

Psychiatric disorders were found in up to 43% of patients with TC. The concomitant PD in TC patients was not associated with increased mortality, AKI, but had higher rates of cardiogenic shock, use of mechanical ventilation and cardiac arrest. The TC group with PD was also associated with increased 30-day readmission, LOS and total charges compared to TC patients without PD.

Impact of chronic kidney disease on in-hospital mortality and clinical outcomes of catheter ablation of ventricular tachycardia: Insights from the national readmission database

BACKGROUND

Catheter ablation is an effective treatment for ventricular tachycardia (VT), albeit the decision to undergo this procedure is often influenced by underlying comorbidities. The present study aims at evaluating the effects of chronic kidney disease (CKD) on clinical outcomes of VT ablation.

METHODS

We identified 7212 patients who presented between 2016 and 2018 and underwent catheter ablation for VT. Their clinical data were retrospectively accrued from the national readmission database (NRD) using the corresponding diagnosis codes. We compared clinical outcomes between patients with chronic kidney disease (CKD group) and patients without. Odds ratios (OR) for the primary and secondary outcomes were calculated, and multivariable regression analysis was utilized to adjust for confounding variables.

RESULTS

Compared with patients without CKD, patients in CKD group were older (mean age 67.9 vs. 60.5 years, P < 0.01), had a longer mean length of stay (8.73 vs. 5.69 days, P < 0.01), and higher in-hospital mortality 113 (6.7%) vs. 119 (2.2%) (OR 2.24, 95% confidence interval (CI) (1.29-3.88), P < 0.01). CKD group patients had increased risk of developing acute kidney injury 726 (43%) vs. 623 (11.3%) (3.69 95% CI (2.87-4.74), P < 0.01).

CONCLUSION

In patients with CKD, VT ablation is associated with worse clinical outcomes in-hospital mortality, acute kidney injury, mean length of stay, and total hospital charge. This significantly influences the decision-making prior to performing this procedure.

A retrospective study on use of palliative care for patients with alcohol related end stage liver disease in United States

BACKGROUND

Palliative care (PC) has been shown to be beneficial in end stage liver disease (ESLD), yet the hospitalization data for PC utilization is unknown.

AIM

To identify the trend of PC utilization for the special population of alcohol-associated ESLD patients, factors affecting its use and ascertain its impact on healthcare utilization.

METHODS

We analyzed around 78 million discharges from the 2007-2014 national inpatient sample and 2010-2014 national readmission database including adult patients admitted for decompensated alcohol-associated cirrhosis. We identified patients with PC consultation as a secondary diagnosis. Odds ratios (OR) and means were adjusted for confounders using multivariate regression analysis models.

RESULTS

Out of the total 1421849 hospitalizations for decompensated liver cirrhosis, 62782 (4.4%) hospitalizations had a PC consult, which increased from 0.8% (1258) of all alcohol-associated ESLD hospitalizations in 2007 to 6.6% in 2014 (P < 0.01). Patient and hospital characteristics associated with increased odds of PC utilization were advanced age, lower income, Medicaid coverage, teaching institution, urban location, length of stay > 3 d, prolonged ventilation, and administration of total parenteral nutrition (all P < 0.01). Palliative encounters in alcohol-associated ESLD and acute-on-chronic liver failure (ACLF) score were associated with increased odds of discharge to a rehabilitation facility, but significantly lower odds of 30-d readmissions (aOR: 0.35, 95%CI: 0.31-0.41), lower total hospitalization charges and lower mean hospitalization days (all P < 0.01).

CONCLUSION

Inpatient PC is sparingly used for patients with decompensated alcohol related liver disease, however it has increased over the past decade. PC consultation is associated with lower 30-d readmission rates on multivariate analysis, and lower hospitalization cost and length of stay in patients with ACLF score ≥ 2.

Thirty-day readmission in patients with heart failure with preserved ejection fraction: Insights from the nationwide readmission database

BACKGROUND

There are rising numbers of patients who have heart failure with preserved ejection fraction (HFpEF). Poorly understood pathophysiology of heart failure with preserved and reduced ejection fraction and due to a sparsity of studies, the management of HFpEF is challenging.

AIM

To determine the hospital readmission rate within 30 d of acute or acute on chronic heart failure with preserved ejection fraction and its effect on mortality and burden on health care in the United States.

METHODS

We performed a retrospective study using the Agency for Health-care Research and Quality Health-care Cost and Utilization Project, Nationwide Readmissions Database for the year 2017. We collected data on hospital readmissions of 60514 adults hospitalized for acute or acute on chronic HFpEF. The primary outcome was the rate of all-cause readmission within 30 d of discharge. Secondary outcomes were cause of readmission, mortality rate in readmitted and index patients, length of stay, total hospitalization costs and charges. Independent risk factors for readmission were identified using Cox regression analysis.

RESULTS

The thirty day readmission rate was 21%. Approximately 9.17% of readmissions were in the setting of acute on chronic diastolic heart failure. Hypertensive chronic kidney disease with heart failure (1245; 9.7%) was the most common readmission diagnosis. Readmitted patients had higher in-hospital mortality (7.9% vs 2.9%, P = 0.000). Our study showed that Medicaid insurance, higher Charlson co-morbidity score, patient admitted to a teaching hospital and longer hospital stay were significant variables associated with higher readmission rates. Lower readmission rate was found in residents of small metropolitan or micropolitan areas, older age, female gender, and private insurance or no insurance were associated with lower risk of readmission.

CONCLUSION

We found that patients hospitalized for acute or acute on chronic HFpEF, the thirty day readmission rate was 21%. Readmission cases had a higher mortality rate and increased healthcare resource utilization. The most common cause of readmission was cardio-renal syndrome.

Association of socioeconomic status with 30- and 90-day readmission following open and laparoscopic hernia repair: a nationwide readmissions database analysis

BACKGROUND

Socioeconomic disparities have been associated with outcomes in many medical conditions. The association of socioeconomic status (SES) with readmissions after ventral and inguinal hernia repair has not been well studied on a national level. This study aims to evaluate the association of SES with readmission as a significant outcome in patients undergoing ventral and inguinal hernia repair.

METHODS

A retrospective cohort study was performed evaluating patients undergoing ventral hernia and inguinal hernia repair with 1:1 propensity score matching using the Nationwide Readmissions Database (2016-2017). Both 30- and 90-day readmissions were examined. After matching, a multivariate logistic regression analysis was performed using confounding variables including hospital setting, comorbidities, urgency of repair, sociodemographic status, and payer. Likelihood of readmission was reported in odds ratio form.

RESULTS

Readmission rates were 11.56% (24,323 out of 210,381) and 17.94% (30,893 out of 172,210) for 30- and 90-day readmissions, respectively. Patients with Medicaid and in the lower income quartile were more likely to present in an emergent fashion for hernia repair. After matching, a multivariate logistic regression analysis showed socioeconomic status (OR 1.250 and 1.229) was a statistically significant independent predictor of readmission at 30 and 90 days, respectively. Inversely, factors associated with the least likely chance of readmission were a laparoscopic approach (OR 0.646 and 0.641), elective admission (OR 0.824 and 0.779), and care in a teaching hospital (OR 0.784 and 0.798).

CONCLUSION

SES is an independent predictor of readmission at 30 and 90 days following open and laparoscopic ventral and inguinal hernia repair. Patients with a lower socioeconomic status were more likely to undergo hernia repair in the emergent setting. Efforts toward mitigating SES disparities by potentially promoting MIS techniques, enhancing access to elective cases, and systematic approaches to perioperative care for this disadvantaged population can potentially enhance overall hernia outcomes.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

BACKGROUND

Sex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (T1MI). However, type 2 myocardial infarction (T2MI) is more common in contemporary practice, with scarce data regarding sex-based differences of outcomes.

METHODS

The Nationwide Readmission Database 2018 was queried for hospitalizations with T2MI as a primary or secondary diagnosis. Complex samples multivariable logistic and linear regression models were used to determine the association between T2MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with T2MI.

RESULTS

A total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with T2MI was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.88-0.96; P < 0.001), shorter LOS (adjusted parameter estimate [aPE] -0.28; 95% CI -0.38-0.17; P < 0.001), less hospital costs (aPE -1510.70; 95% CI -1916.04-1105.37; P < 0.001), and increased nursing home discharges (aOR 1.08; 95% CI 1.05-1.12; P < 0.001) compared to males with T2MI. Females and males with T2MI had similar rates of 30-day all-cause readmission (aOR 1.00; 95% CI 0.97-1.04; P = 0.841).

CONCLUSION

Among T2MI hospitalizations, females have lower in-hospital mortality, hospitalization costs, shorter LOS, and increased rates of nursing home discharge compared to males. Although statistically significant, the clinical significance of these small differences are unknown and require future studies.

National Landscape of Unplanned 30-Day Readmission Rates for Acute Non-hemorrhagic Diverticulitis: Insight from National Readmission Database

BACKGROUND

Early readmissions are an important indicator of the quality of care. Limited data exist describing hospital readmissions in acute diverticulitis. The study aimed to describe unplanned, 30-day readmissions among adult acute diverticulitis patients and to assess readmission predictors.

METHODS

We analyzed the 2013 and 2014 United States National Readmission Database and identified acute diverticulitis admissions using administrative codes in adult patients older than 18 years of age. Our primary outcome was a 30-day, unplanned readmission rate. We used Chi-square tests, t tests, and Wilcoxon rank-sum tests for descriptive analyses and survey logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals for associations with readmissions adjusting for confounders.

RESULTS

In the cohort of 364,511 hospitalizations with acute diverticulitis, as the primary diagnosis on index admission, 31,420 (8.6%) had at least one unplanned 30-day readmission. Sixty percent of the readmissions occurred within the first 2 weeks of the index admission. The most common reasons for unplanned 30-day readmission were due to diverticulitis of the colon (41.5%), postoperative infection (4.2%), septicemia (3.6%), intestinal infection due to Clostridium difficile (3%), and other digestive system complications such bleeding or fistula (2.8%). Multivariable analysis showed advance age (> 75 years), discharge against medical advice, comorbidities (renal failure, coronary artery disease, atrial fibrillation, congestive heart failure, hypertension, diabetes, obesity, weight loss, chronic lung disease, malignancy), blood transfusion, Medicare and Medicaid insurance, and increased length of stay (> 3 days) were associated with significantly higher odds for readmission. Patients who have undergone abdominal surgery during index admission were 31% less likely to get readmitted.

CONCLUSIONS

On a national level, 1 in 11 hospitalizations for acute diverticulitis was followed by unplanned readmission within 30 days with most admissions occurring in the first 2 weeks. Multiple modifiable and non-modifiable factors influencing readmission rates were noted. Further studies should examine if strategies that address these predictors can decrease readmissions.

A nationwide analysis of maternal morbidity and acute postpartum readmissions in women with epilepsy

OBJECTIVE

To compare maternal delivery hospitalization characteristics and postpartum outcomes in women with epilepsy (WWE) versus women without common neurological comorbidities.

METHODS

We performed a retrospective cohort analysis of index characterizations and short-term postpartum rehospitalizations after viable delivery within the 2015-2017 National Readmissions Database using International Classification of Diseases, Tenth Revision codes. Wald chi-squared testing compared baseline demographic, hospital and clinical characteristics and postpartum complications between WWE and controls. Multivariable logistic regression models examined odds of nonelective readmissions within 30 and 90 days for WWE compared to controls (alpha = 0.05).

RESULTS

A total of 38,518 WWE and 8,136,335 controls had a qualifying index admission for delivery. Baseline differences were most pronounced in Medicare/Medicaid insurance (WWE: 58.2%, controls: 43%, p < 0.0001), alcohol/substance abuse (WWE: 8.3%, controls: 2.5%, p < 0.0001), psychotic disorders (WWE: 1.2%, controls 0.1%, p < 0.0001), and mood disorder (WWE: 15.5%, controls: 3.7%, p < 0.0001). At the time of delivery, WWE were more likely to have edema, proteinuria, and hypertensive disorders (WWE: 19%, controls: 12.9%, p < 0.0001); a history of recurrent pregnancy loss (WWE: 1%, controls: 0.4%, p < 0.0001); preterm labor (WWE: 7.3%, controls: 4.8%, p < 0.0001), or presence of any Center for Disease Control severe maternal morbidity indicator (WWE: 3.2%, controls: 0.6%, p < 0.0001; AOR 5.16, 95% CI 4.70-5.67, p < 0.0001). A higher proportion of WWE were readmitted within 30 days (WWE: 2.4%, controls: 1.1%) and 90 days (WWE: 3.7%, controls: 1.6%). After adjusting for covariates, the odds of postpartum nonelective readmissions within 30 days (AOR 1.86, 95% CI 1.66-2.08, p-value <0.0001) and 90 days (AOR 2.04, 95% CI 1.83-2.28, p-value <0.0001) were higher in WWE versus controls.

INTERPRETATION

Women with epilepsy experienced critical obstetric complications and a higher risk of severe maternal morbidity indicators at the time of delivery. Although relatively low, nonelective short-term readmissions after delivery were higher in WWE than women without epilepsy or other common neurological comorbidities. Further research is needed to address multidisciplinary care inconsistencies, improve maternal outcomes, and provide evidence-based guidelines.

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.

Risk of readmission for injury in patients with epilepsy in the United States - A population-based study

OBJECTIVE

The objective of this study was to determine the 30-day injury readmission risk among persons with epilepsy vs. without epilepsy using a nationally representative US database. Secondary objectives were to examine the factors associated with injury-related readmissions among those with epilepsy and identify specific causes of readmissions within 30 days of index admission.

METHODS

Hospitalized individuals of all ages with epilepsy as the primary diagnosis were identified using validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes in the 2014 Nationwide Readmission Database (NRD). Primary outcome was 30-day readmission for an injury defined by ICD-9-CM diagnosis codes following discharge from index hospitalization. Subgroup differences in the groups with epilepsy and without epilepsy were estimated using standardized mean difference scores that are calculated with means and variances of the covariates. Multinomial logistic regressions were conducted to determine the 30-day injury readmission risk and examine the factors associated with injury-related readmissions.

RESULTS

There were 60,074 unique persons with epilepsy (mean age: 42.53 years, female: 49.32%) and 9,282,952 without epilepsy (mean age: 44.46 years, female: 59.43%). A higher proportion of persons with epilepsy (n = 215, 0.34%) vs. without epilepsy (n = 22,783, 0.22%) had a 30-day readmission due to an injury. After adjusting for covariates, persons with epilepsy had higher odds of 30-day readmission due to an injury (adjusted OR: 1.40, 95% CI: 1.20-1.62, p < 0.0001). Factors associated with an injury-related readmission in persons with epilepsy include the following: increasing age (OR: 1.01, 95% CI: 1.00-1.02, p = 0.02), transfer to short term hospital/other facility (OR: 1.50, 95% CI: 1.00-2.27, p = 0.05), discharged against medical advice/discharge destination unknown (OR: 2.26, 95% CI: 1.40-4.45, p = 0.02), and higher Elixhauser comorbidity index (OR: 1.02, 95% CI: 1.01-1.03, p < 0.0001).

CONCLUSIONS

Higher odds of 30-day injury readmissions were observed in persons with epilepsy vs. without epilepsy. Optimizing the management of comorbid conditions during the patient's index admission for epilepsy, minimizing discharges against medical advice, and fostering outreach programs to those who have been transferred to short-term hospitals or facilities may reduce 30-day readmissions due to an injury.

Predictors of 30- and 90-day readmission following craniotomy for malignant brain tumors: analysis of nationwide data

Hospital readmissions are a major contributor to increased health care costs and are associated with worse patient outcomes after neurosurgery. We used the newly released Nationwide Readmissions Database (NRD) to describe the association between patient, hospital and payer factors with 30- and 90-day readmission following craniotomy for malignant brain tumor. All adult inpatients undergoing craniotomy for primary and secondary malignant brain tumors in the NRD from 2013 to 2014 were included. We identified all cause readmissions within 30- and 90-days following craniotomy for tumor, excluding scheduled chemotherapeutic procedures. We used univariate and multivariate models to identify patient, hospital and administrative factors associated with readmission. We identified 27,717 admissions for brain tumor craniotomy in 2013-2014, with 3343 (13.2%) 30-day and 5271 (25.7%) 90-day readmissions. In multivariate analysis, patients with Medicaid and Medicare were more likely to be readmitted at 30- and 90-days compared to privately insured patients. Patients with two or more comorbidities were more likely to be readmitted at 30- and 90-days, and patients discharged to skilled nursing facilities or home health care were associated with increased 90-day readmission rates. Finally, hospital procedural volume above the 75th percentile was associated with decreased 90-day readmission rates. Patients treated at high volume hospitals are less likely to be readmitted at 90-days. Insurance type, non-routine discharge and patient comorbidities are predictors of postoperative non-scheduled readmission. Further studies may elucidate potentially modifiable risk factors when attempting to improve outcomes and reduce cost associated with brain tumor surgery.