Prevalence and prognosis of seizures among patients undergoing mechanical thrombectomy for acute ischemic stroke: A look at pre-2015 aha/asa guidelines update regarding endovascular treatment.

BACKGROUND: Mechanical Thrombectomy (MT) is standard of care for eligible patients with Acute Ischemic Stroke (AIS) due to large vessel occlusion (LVO). With increasing use of MT, clinicians are more likely to encounter seizures, a potential complication of AIS treated with MT. Tracking future trends in the burden of post-stroke seizure associated with MT will require baseline pre-approval benchmark estimates of its frequency and outcomes. METHODS: All patients with AIS who underwent MT (International Classification of Diseases, Ninth Revision, Clinical Modification; ICD-9-CM procedure code: 39.74) were identified from the National Inpatient Sample (NIS) 2006-2014, using appropriate ICD-9-CM codes. We identified a subset of patients with seizures using ICD-9-CM secondary discharge diagnoses codes 780.3x and 345.x. We computed the rate of seizures overall and across pre-specified demographic, clinical, and healthcare system-related variables. Finally, we assessed the independent association of mortality with seizures using a multivariable logistic regression model. RESULTS: Of 30137 (weighted) patients with AIS who underwent MT, 1,363 (4.5%) had seizures. Patients who had seizures were younger, privately insured, or Medicaid beneficiaries, and frequently died in the hospital. There were no statistically significant differences between the seizures and no-seizures groups by race, sex, IV thrombolysis with recombinant tissue plasminogen activator, length of stay, and the number of medical comorbidities. However, patients who underwent MT and developed seizures had 75% higher odds of in-hospital mortality (adjusted OR 95% CI 1.75; 1.22-2.49). CONCLUSION: In this nationwide sample, prior to the 2015 AHA/ASA guidelines update supporting MT use, seizures occurred in one of twenty patients with AIS treated with MT, and occurrence of seizure was independently associated with a nearly two-fold increase in the odds of in-hospitality death.

The association of multiple chronic conditions and healthcare expenditures among adults with epilepsy in the United States.

RATIONALE: Epilepsy is a frequent neurologic condition with important financial strains on the US healthcare system. The co-occurrence of multiple chronic conditions (MCC) may have additional financial repercussions on this patient population. We aimed to assess the association of coexisting chronic conditions on healthcare expenditures among adult patients with epilepsy. METHODS: We identified a total of 1,942,413 adults (≥18 years) with epilepsy using the clinical classification code 83 from the MEPS-HC (Medical Expenditure Panel Survey Household Component) database between 2003 and 2014. Chronic conditions were selected using the clinical classification system (ccs), and categorized into 0, 1, or 2 chronic conditions in addition to epilepsy. We computed unadjusted healthcare expenditures per year and per individual (total direct healthcare expenditure, inpatient expenditure, outpatient expenditure, prescription medication expenditure, emergency room visit expenditure, home healthcare expenditure and other) by number of chronic conditions. We applied a two-part model with probit (probability of zero vs non-zero cost) and generalized linear model (GLM) gamma family and log link (for cost greater than zero) to examine the independent association between chronic conditions, and annual expenditures per individual, generating incremental costs with 0 chronic condition as reference. RESULTS: Over half of the patients with epilepsy had at least two chronic conditions (CC). Yearly, for each patient with one and two chronic conditions, unadjusted total healthcare expenditures were two times ($10,202; 95 %CI $6,551-13,853) to nearly three times ($21,277; 95 %CI $12,971-25,583) higher than those with no chronic conditions ($6,177; 95 %CI $4,895-7,459), respectively. In general healthcare expenditures increased with the number of chronic conditions for pre-specified cost categories. The incremental (adjusted) total healthcare expenditure increased with the number of chronic conditions (1CC vs 0 CC: $3,238; 95 %CI $524-5,851 p-value = 0.015 and ≥2 CC vs 0 CC: $8,145; 95 %CI $5,935-10,895 p-value < 0.001). In general, for all cost categories, incremental healthcare expenditures increased with the number of chronic conditions with the largest increment noted between those with 2 CC and those with 0 CC for inpatient ($2,025: 95 %CI $867-3,1830), outpatient ($2,141; 95 %CI $1,321-2,962), and medication ($1,852; 95 %CI $1,393-2,310). CONCLUSION: Chronic conditions are frequent among adult patients with epilepsy and are associated with a dose-response increase in healthcare expenditure, a difference driven by inpatient, outpatient, and medication prescription expenditures. Greater coordination of epilepsy care accounting for the presence of multiple chronic conditions may help lower the cost of epilepsy.

Decompressive hemicraniectomy for stroke by race/ethnicity in the United States.

Objective: Racial and ethnic differences in the performance of indicated neurosurgical procedures have been reported. However, it is not clear whether there are racial or ethnic differences in the performance of decompressive hemicraniectomy (DHC) for acute ischemic stroke. This study evaluated the rate, trends, and independent association of race and ethnicity with DHC among hospitalized ischemic stroke patients in the United States. Materials and methods: We used the International Classification of Diseases, Clinical Modification (ICD-9-CM) to identify adult patients (18-year-old and older) with a primary discharge diagnosis of ischemic stroke, excluding those with a posterior circulation ischemic stroke in the Nationwide Inpatient Sample between 2006 and 2014. We computed the rate and trends of DHC. We then applied a multivariable logistic regression model to evaluate the independent association of race with DHC. Results: A total 715,649 patients had anterior ischemic stroke, including 1514 who underwent DHC (2.1 per 1000). The rate of DHC increased overall from 1 per 1000 in 2006 to 3 per 1000 in 2014. Similar upward trends were noted among Non-Hispanic Whites, Non-Hispanic Blacks, and Hispanics. Hispanics with anterior ischemic stroke were 1.28 times more likely than non-Hispanic Whites to have DHC but no difference was observed between Non-Hispanic Blacks and Non-Hispanic Whites. Conclusions: In this nationally representative sample of patients with anterior ischemic strokes, being of Hispanic ethnicity was independently associated with a higher frequency of receiving DHC compared to being Non-Hispanic White. Future studies should confirm this difference and explore the underlying reasons for it.

Prevalence, predictors, and prognosis of mortality among elderly stroke patients with convulsive status epilepticus in the United States.

BACKGROUND: Stroke is the most common cause of epilepsy in the elderly. However, despite the high mortality typically associated with convulsive status epilepticus (CSE), there is a dearth of nationwide data on the magnitude and association of CSE with mortality among hospitalized elderly with stroke in the United States. METHODS: We analyzed the 2006-2014 National Inpatient Sample (NIS) to identify elderly patients (65+ years) with a primary discharge diagnosis of stroke using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes 433.X1, 434.X1, 436, 430, 431, 432.0, 432.1, and 432.9. We examined a subgroup with a secondary discharge diagnosis of convulsive status epilepticus (ICD-9-CM: 345.3). We estimated the hospital mortality rate by CSE status and then evaluated the independent association of CSE and other key factors with mortality among hospitalized elderly with stroke. RESULTS: A total of 1220 elderly patients (0.14%) had a secondary discharge diagnosis of CSE. Inpatient mortality rate was 25.8% among those with CSE vs. 7.7% for non-CSE patients. CSE was independently associated with a 4-fold increased odds of in-hospital death. Increased age, medical comorbidities, weekend admissions, being a Medicare beneficiary, and hospitalization in large urban teaching hospitals were also independently associated with a greater likelihood of in-hospital death. The small number of events did not allow analysis by stroke subtypes. CONCLUSION: While CSE occurs in just 14 of 10,000 hospitalized elderly stroke patients in the United States, it is associated with a 4-fold higher odds of in-hospital death.

The Magnitude and Potential Causes of Sex Disparities in Statin Therapy in Veterans with Type 2 Diabetes: A 10-year Nationwide Longitudinal Cohort Study.

BACKGROUND: Past research has shown that women eligible for statin therapy are less likely than their male counterparts to receive any statin therapy or be prescribed a statin at the guideline-recommended intensity. We compared statin treatment in men and women veterans from a national cohort of older veterans with type 2 diabetes. METHODS: The Veterans Health Administration Corporate Data Warehouse and Centers for Medicare and Medicaid Services data were used to create a unique dataset and perform a longitudinal study of veterans with type 2 diabetes from 2007 to 2016. Mixed-effects logistic regression was used to model the association between the primary exposure (sex) and statin use. RESULTS: The study included 714,212 veterans with diabetes, including 9,608 women, with an overall mean age of 75.9 years. In the unadjusted model for any statin use, women veterans had a 14% significantly lower odds of having any statin use compared with men. After adjusting for all covariates, including markers of Veterans Administration care use (service-connected disability rating, Veterans Administration use, and primary care visits) that serve as proxies for access and mental health comorbidities (depression and psychiatric disorder), this disparity narrowed from 14% to 3% and was no longer statistically significant. In the model for high-intensity statin therapy (high-intensity vs. low or none), women were 10% less likely than men to use high-intensity statins in the base model that included only time and sex. After adjusting for all measured covariates, the direction of the association changed and women had 16% higher odds of high-intensity statin use compared with men (odds ratio, 1.16; 95% confidence interval, 1.03-1.31). CONCLUSIONS: Consistent with prior research, in the unadjusted analysis a significant sex disparity was observed in statin use, with lower rates observed in women. For the outcome of any statin use, after adjustment for covariates that included variables that are proxies for access as well as psychiatric and depression comorbidities, this disparity lost statistical significance and narrowed. In the high-intensity statin versus low or none model, the direction of the association changed after controlling for measured covariates and women had a 16% higher odds of high-intensity statin use compared with men. This study highlights a persistent health disparity in lipid-lowering therapy for women veterans. Additional research is needed to further elucidate the reasons for and develop interventions to mitigate this persistent sex disparity in cholesterol management for veterans with diabetes.

Factors Associated With Prolonged Length of Stay in Patients Hospitalized With Generalized Convulsive Status Epilepticus in the United States.

OBJECTIVE: Generalized convulsive status epilepticus (GCSE) is a severe complication of epilepsy, which typically requires extended hospitalization, resulting in substantial resource utilization, hospital expenditures, and patient costs. In this nationwide analysis, we examined hospital length of stay (LOS) patterns for GCSE, and the factors that influence prolonged LOS. METHODS: We extracted data for adult patients (age 18 years and above) with a primary discharge diagnosis of GCSE from the National Inpatient Sample (NIS) from 2006-2014, the largest all-payer inpatient care database in the United States. We computed LOS (≤1, 2-6, and ≥7 days), overall, and across pre-specified patient-related, hospital-related, and healthcare system-related variables available in the NIS. We identified factors independently associated with prolonged hospitalization (2 or more days), using a multivariable logistic regression model. RESULTS: Of 57,832 discharged with a primary diagnosis of GCSE, 6,133 (10.7%) had a LOS ≤1 day, 27,327 (7.3%) stayed for 2-6 days, and 24,372 (42.1%) stayed for ≥7 days. After adjusting for confounders, patients who were older, female, Black, and Hispanic, who underwent continuous EEG video monitoring, were Medicare beneficiaries, had medical comorbidities, or were admitted to large/urban hospitals, were all significantly more likely to have prolonged LOS. CONCLUSION: Over 40% of patients hospitalized for GCSE in the United States spend at least a week in the hospital. Efforts to shorten hospitalization for GCSE may need to primarily focus on patient groups with select sociodemographic and clinical characteristics.

Trends in Medical Expenditures by Race/Ethnicity in Adults with Type 2 Diabetes 2002-2011.

OBJECTIVE: The objective of the study was to examine racial/ethnic differences in medical expenditures (prescription, office-based, in-patient, out-patient, emergency room, total) over time, overall and by type of expenditure, in a nationally representative sample of adults with diabetes. METHODS: A weighted sample of 17,820,243 adults aged ≥18 with diabetes from the Medical Expenditure Panel Survey (MEPS) dataset from 2002 to 2011 were analyzed for this study. Multiple comparison testing and general linear model (GLM) were used to test for differences in expenditures by race. Total unadjusted expenditures by racial/ethnic category stratified by different insurance categories (privately insured, publicly insured, uninsured and overall) were also estimated. RESULTS: Non-Hispanic Whites (NHW) had more than $4000 higher expenditures than Hispanics and Other races (p < 0.0001). Prescription costs were about $410 less for Non-Hispanic Blacks (NHB) (p < 0.0001), and more than $600 less for Hispanics (p < 0.0001) and Others (p < 0.0001) compared to NHW. CONCLUSION: Minority groups with type 2 diabetes were found to have significantly less total expenditures, with the exception of total expenditures for NHB compared to NHW. These findings indicate minorities with type 2 diabetes may be receiving less care than NHW, which has implications for the known disparities in health outcomes and complications in individuals with diabetes.

Early-hospital readmission after generalized status epilepticus during stroke hospitalization.

OBJECTIVE: To assess the relationship between generalized convulsive status epilepticus (GCSE) during an index stroke hospitalization and occurrence of 30-day hospital readmission. METHODS: Retrospective analysis of data within the 2014 National Readmission Database, a national dataset tracking readmissions in the United States. We identified patients with an index discharge diagnosis of stroke using the International Classification of Disease, Ninth Revision, Clinical Modification (433.X1, 434.X1, and 436 for ischemic stroke and 430, 431, 432.0, 432.1, and 432.9 for hemorrhagic stroke) and a subset of patients with GCSE (345.3). We explored the association between GCSE and 30-day readmission using multivariable logistic regression, while applying recommended survey weights. RESULTS: Of 271,148 adults with a primary diagnosis of stroke hospitalizations in the US in 2014, 591 (0.21%) had GCSE. The prevalence of GCSE was 0.14% among ischemic stroke patients and 0.64% among hemorrhagic stroke patients. Readmission rates were 11.9% for all strokes, 11.6% for ischemic strokes, and 14.2% for hemorrhagic strokes. Readmission rates were significantly higher for those with GCSE vs. without GCSE regardless of stroke type. Adjusted odds ratios for the association of GCSE with 30-day readmission were 1.30 (95% CI: 1.02-1.65) for all strokes, 1.19 (95% CI: 0.84-1.71) for ischemic strokes, and 1.39 (95% CI: 0.92-2.10 0.09) for hemorrhagic stroke. CONCLUSION: Approximately one in eight hospitalized stroke patients who experience in-hospital GCSE are re-admitted to a hospital within 30 days with a nominally higher rate of readmissions among those with hemorrhagic stroke.

Association of seizure co-morbidity with early hospital readmission among traumatic brain injury patients.

OBJECTIVE: To assess the frequency of seizure co-morbidity and its independent association with 30-day readmission rate among patients hospitalized with traumatic brain injury (TBI) in the United States. METHODS: The data source was the 2014 Nationwide Readmission Database. We included adults (Age ≥18 years) with a primary discharge diagnosis of TBI, identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 800.0, 801.9, 803.0, 804.9, 850.0-854.1, and 959.01. Seizures were diagnosed using the ICD-9-CM codes of 345.x and 780.39. Overall and across pre-specified groups 30-readmission rate was computed. Logistic regression analysis was used to identify independent predictors of 30-day readmission. RESULTS: Among 76,062 unweighted adults discharged with a diagnosis of TBI, 7,776 (10.14%) had a secondary discharge diagnosis of seizures.A total of 1,751 (2.3%) patients with a primary discharge diagnosis of TBI were readmitted within 30 days. On multivariate logistic analysis, patients discharged with a secondary diagnosis of seizures were 18% more likely to be readmitted within 30 days compared to those without seizures (OR 1.18, 95% CI: 1.01-1.39, P = .42). CONCLUSION: One in 10 patients hospitalized with TBI in the US have a co-morbid seizure disorder. Seizure co-morbidity conferred 18% greater odds of being readmitted within 30 days.

Sudden cardiac arrest in epilepsy patients undergoing continuous video electroencephalogram monitoring: The national inpatient sample.

OBJECTIVE: To examine the relationship between epilepsy and sudden cardiac arrest (SCA) and identify clinical and healthcare system related predictors of SCA in patients with a discharge diagnosis of epilepsy undergoing continuous video EEG (cVEEG) monitoring. METHODS: The national inpatient sample was used as data source to identify adults (18 years and older) with a primary discharge diagnosis of epilepsy who were at some point during their hospitalization on cVEEG monitoring. We applied a logistic regression model to identify independent patient-related and hospital/healthcare system-related factors associated with SCA. RESULTS: A total of weighted 10,059 (0.71 %) patients with epilepsy on cVEEG had a secondary discharge diagnosis of SCA. The main independent factors associated with SCA were the presence of any of the following secondary discharge diagnoses: paroxysmal arrhythmia (OR: 2.29, 95 %CI: 1.96-2.66), myocardial infarction (OR: 3.78, 95 %CI: 2.83-5.05), congestive heart failure (OR: 2.27, 95 %CI: 1.93-2.62), and anoxic brain injury (OR: 57.6, 95 %CI: 50.83-67.27). There was no association between refractory epilepsy and SCA (OR: 0.99, 95 %CI: 0.51-1.93). CONCLUSION: SCA is a rare event occurring in < 1% of patients with epilepsy undergoing cVEEG monitoring in the United States. Key independent contributors to occurrence of SCA are presence of select cardiovascular conditions and anoxic brain injury.

Joint effect of race/ethnicity or location of residence and sex on low density lipoprotein-cholesterol among veterans with type 2 diabetes: a 10-year retrospective cohort study.

BACKGROUND: Cardiovascular (CV) disease is the leading cause of death among United States women. Rural residence and ethnic-minority status are individually associated with increased CV mortality. Managing dyslipidemia is important in the prevention of CV mortality. However, the impact of race/ethnicity and location of residence on sex differences in dyslipidemia management is not well understood. Therefore, we sought to understand the joint effects of race/ethnicity and location of residence on lipid management differences between veteran men and women with type 2 diabetes (T2D). METHODS: Veterans Health Administration and Centers for Medicare and Medicaid Services data were used to perform a longitudinal cohort study of veterans with T2D (2007-2016). Mixed effects logistic regression with a random intercept was used to model the association between sex and low-density lipoprotein (LDL) > 100 mg/dL and its interaction with race/ethnicity and location of residence after adjusting for all measured covariates. RESULTS: When female sex and rural location of residence were both present, they were associated with an antagonistic harmful effect on LDL. Similar antagonistic harmful effects on LDL were observed when the joint effect of female sex and several minority race/ethnicity groups were evaluated. After adjusting for measured covariates, the odds of LDL > 100 mg/dL were higher for urban women (OR = 2.66, 95%CI 2.48-2.85) and rural women (OR = 3.26, 95%CI 2.94-3.62), compared to urban men. The odds of LDL > 100 mg/dL was the highest among non-Hispanic Black (NHB) women (OR = 5.38, 95%CI 4.45-6.51) followed by non-Hispanic White (NHW) women (OR = 2.59, 95%CI 2.44-2.77), and Hispanic women (OR = 2.56, 95%CI 1.79-3.66). CONCLUSION: Antagonistic harmful effects on LDL were observed when both female sex and rural location of residence were present. These antagonistic effects on LDL were also present when evaluating the joint effect of female sex and several minority race/ethnicity groups. Disparities were most pronounced in NHB and rural women, who had 5.4 and 3.3 times the odds of elevated LDL versus NHW and urban men after adjusting for important covariates. These striking effect sizes in a population at high cardiovascular risk (i.e., older with T2D) suggest interventions aimed at improving lipid management are needed for individuals falling into one or more groups known to face health disparities.

Contemporary relationship between medical expenditures and quality of life among adults with epilepsy in the United States.

AIMS: Epilepsy exacts substantial adverse economic and quality of life (QoL) costs. Clarifying the quantitative and qualitative relationships between total and out-of-pocket (OOP) healthcare expenditures and QoL could shed insights into how they influence each other, and have done so over recent times. METHODS: We used the Medical Expenditure Household Components 2003-2014 to identify a total of 2450 adults with epilepsy, representing a weighted population of 1,942,413. Quality of life was assessed using the Physical Component Summary (PCS) and the Mental Component Summary (MCS) derived from the Short-form 12 Version 2 (SF-12 V2), converted into quartiles of equal distribution, with higher quartiles indicating a better QoL. We computed unadjusted mean and adjusted (through a generalized linear model (GLM)) total and OOP healthcare expenditures by QoL categories among adults with epilepsy (reported as dollars in 2016). RESULTS: The pooled estimates of total healthcare expenditures decreased as PCS and MCS quartiles of QoL increased [PCS: costs for quartile 1 = $21,792 (95% confidence interval (CI): $18,416-$25,168 vs. costs for quartile 4 = $6057 (95% CI: $4648-$7466) and MCS: costs for quartile 1 = $19,040 (95% CI: $15,544-$22,535) vs. quartile 4 = $12,939 (95% CI: $8450-$17,429)]. Similarly, the pooled estimates of OOP healthcare expenditures and QoL were inversely related [PCS: costs for quartile 1 = $1849 (95% CI: $1583-$2114) vs. costs for quartile 4 = $948 ($709-$1187) and MCS: costs for quartile 1 = 1812 (95% CI: $1483-2141) vs. quartile 4 = $1317 (95% CI: $982-$1652)]. The association between QoL and total and OOP healthcare expenditures was unchanged after adjusting for socioeconomic and healthcare system related confounders in the GLM. Overall, healthcare expenditures were stable across years independently of the QoL; only OOP expenditures decreased between 2003-2006 and 2011-2014 for quartile 1 of PCS and MCS. CONCLUSION: Quality of life and OOP health expenditures are independently and inversely related to each other among adults with epilepsy. Over the decade studied in the United States, there was a decrease in OOP health expenditures among those patients with epilepsy with the lowest QoL, possibly reflecting a rise in insurance coverage after the Affordable Care Act.

An Evaluation of Statin Use Among Patients with Type 2 Diabetes at High Risk of Cardiovascular Events Across Multiple Health Care Systems.

BACKGROUND: Patients with more than one chronic condition often receive care from several providers and facilities, which may lead to fragmentation of care. Poor care coordination in dual health care system use has been associated with increased emergency department visits, hospitalizations, and costs. OBJECTIVE: Dual health care system use is increasing among veterans, and we sought to evaluate the effect of dual health care system use on statin treatment in veterans with type 2 diabetes at high risk of cardiovascular events, using varying degrees of Centers for Medicare & Medicaid Services (CMS) services. METHODS: This was a 10-year retrospective longitudinal cohort study of national clinical and administrative data that included 689,138 veterans with type 2 diabetes who were aged 65 years or older on January 1, 2006. Patients were followed from January 1, 2007, until December 31, 2016. Administrative and clinical data from the Veterans Health Administration's (VHA) Corporate Data Warehouse were merged with CMS inpatient, outpatient, and pharmacy data. Statin use was defined as any therapy and subcategorized as high versus low or moderate intensity per the American College of Cardiology/American Heart Association guidelines. Marginal generalized estimating equation-type models for longitudinal data were used to model the association between dual health care utilization status (< 50%, 50%-80%, and > 80% VHA utilization, with the first group serving as the reference group) and statin use after adjusting for measured covariates. RESULTS: The mean ages at baseline for each group were similar and ranged between 75.4 and 76.9 years. For the outcome of any statin use, the group with < 50% VHA utilization was significantly less likely to receive statin therapy compared with the group with > 80% VHA utilization (OR = 0.26, 95% CI = 0.26-0.26), while the group with 50%-80% VHA utilization was slightly more likely (OR = 1.05, 95% CI = 1.04-1.07). Similarly, for the high-intensity versus low-/moderate-intensity or no statins outcome, the group with < 50% VHA utilization was significantly less likely to receive a high-intensity statin compared with the group with > 80% VHA utilization (OR = 0.56, 95% CI = 0.55-0.57), while the group with 50%-80% VHA utilization was only slightly less likely (OR = 0.95, 95% CI =0.94-0.96). CONCLUSIONS: Among veterans with diabetes at high risk of cardiovascular events, dual health care system utilization status appeared to affect statin use. We observed lower odds for any statin use and high-intensity statin therapy among the cohort with the lowest degree of VHA utilization (i.e., < 50%). Interventions to increase statin use among veterans at high risk of cardiovascular events with lower degrees of VHA utilization should be explored. DISCLOSURES: This study was supported by a grant funded by the Department of Veterans Affairs' Health Services Research and Development Service and was undertaken at the Health Equity and Rural Outreach Center (HEROIC) at Ralph H. Johnson Veteran Affairs Medical Center, Charleston, SC. The authors report no potential conflicts of interest relevant to this article. This article represents the views of the authors and not those of the Medical University of South Carolina or Veteran Health Administration.

Frequency and predictors of 30-day readmission after an index hospitalization for generalized convulsive status epilepticus: A nationwide study.

OBJECTIVE: The objective of the study was to assess the frequency and factors associated with all-cause 30-day readmission among patients hospitalized with generalized convulsive status epilepticus (GCSE) in a nationwide sample in the United States. METHODS: We used The 2014 Nationwide Readmission Database (NRD) as the data source. We included adults (age ≥18 years) with a primary discharge diagnosis of GCSE, identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 345.3. We excluded patients who died during hospitalization and those who had missing information on the length of stay (LOS). We also excluded those discharged in December 2014. We computed the overall 30-day readmission rate and compared prespecified groups by their 30-day readmission status. We applied a multiple logistic regression analysis to identify independent predictors of all-cause 30-day readmission adjusting for potential confounders. RESULTS: Among 14,562 (weighted 31,062) adults discharged with a diagnosis of GCSE, 2520 (17.3%) were readmitted within 30 days. In multivariate analysis, patients with comorbid conditions (odds ratio (OR) for Charlson Comorbidities Index (CCI) = 1 and ≥2 was 1.12, 95% confidence interval (CI): 1.0-1.36 and 1.32, 95% CI: 1.17-1.48, respectively), LOS >6 days (OR: 1.42; 95% CI: 1.05-192), discharged against medical advice (OR: 1.45; 95% CI: 1.09-1.92), or discharged to a short-term hospital (OR: 1.39; 95% CI: 1.0-1.88), had higher odds of 30-day readmission, while there was an inverse association for those aged ≥45 years or with high income. Seizures were the most common cause associated with readmission, followed by sepsis and cerebrovascular diseases, respectively. SIGNIFICANCE: Little is known about the frequency and predictors of early readmission after GCSE. This study showed that more than one in six patients with GCSE was readmitted within 30 days after discharge. More considerable attention to high-risk subgroups may identify opportunities to ameliorate the clinical outcome and lessen the economic burden of early readmission after GCSE.

Trends in documented cannabis use disorder among hospitalized adult epilepsy patients in the United States.

OBJECTIVE: Patients with epilepsy are at increased risk for mental health and substance abuse disorders. Given ongoing contemporary societal controversies about medicinal and recreational cannabis use, we aimed to ascertain recent nationwide prevalence, trends, and psychiatric diagnoses associated with cannabis use disorders (CUD) among epilepsy patients. METHODS: We interrogated the National Inpatient Sample database comprising a total of 398,936 adults (aged 18 years and above) with epilepsy between the years 2006 and 2014, identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 780.39 and 345.X. A subset of these patients with a secondary discharge diagnosis of CUD (ICD-9-CM: 304.30, 304.31, 304.32, 305.20, 305.21, and 305.22), excluding those in remission, were selected. Logistic regression model adjusting for gender, race, age, primary payer, bed size, household income, region, teaching hospital, admission day, length of stay (LOS), Charleson Comorbidity Index (CCI) and, year category was used to ascertain the independent associations of demographic features and mental health comorbidities with CUD. Finally, we generated CUD trend estimates overall and by psychiatric diagnoses. RESULTS: Of all hospitalized patients with epilepsy, 3.19 % had CUD. After adjusting for confounders, CUD was higher in males, Blacks, those aged 18-44 years, those with lower incomes, and those hospitalized during more recent years. CUD was more likely to be present in epilepsy patients with depression, bipolar disorder, and tobacco use disorder (TUD). In contrast, alcohol use disorder (AUD) was associated with lower odds of CUD. Overall, CUD prevalence more than doubled among epilepsy patients (2.18 % in 2006 to 4.41 % in 2014). Among patients with PTSD, CUD prevalence increased over fivefold, and it nearly tripled in those with tobacco use disorder. SIGNIFICANCE: Documented CUD has doubled among hospitalized patients with epilepsy in the United States over the last decade and is especially more prevalent in specific demographic and mental health disorder groups. Increased awareness and potential screening for CUD in high-risk epilepsy patients may be warranted, given the risk for potential complications.

Estimating the Economic Burden of Acute Myocardial Infarction in the US: 12 Year National Data.

BACKGROUND: Acute myocardial infarction (AMI) carries a substantial mortality and morbidity burden. The purpose of this study is to provide annual mean cost per patient and national level estimates of direct and indirect costs (lost productivity from morbidity and premature mortality) associated with AMI. METHODS: Nationally representative data spanning 12 years (2003-2014) with a sample of 324,869 patients with AMI from the Medical Expenditure Panel Survey (MEPS) were analyzed. A novel 2-part model was used to examine the excess direct cost associated with AMI, controlling for covariates. To estimate lost productivity from morbidity, an adjusted Generalized Linear Model was used for the differential in wage earnings between participants with and without AMI. Lost productivity from premature mortality was estimated based on published data. RESULTS: The total annual cost of AMI in 2016 dollars was estimated to be $84.9 billion, including $29.8 billion in excess direct medical expenditures, $14.6 billion in lost productivity from morbidity and $40.5 billion in lost productivity from premature mortality between 2003 and 2014. In the adjusted regression, the overall excess direct medical expenditure of AMI was $7,076 (95% confidence interval [CI] $6,028-$8,125) higher than those without AMI. After adjustment, annual wages for patients with AMI were $10,166 (95% CI -$12,985 to -$7,347) lower and annual missed work days were 5.9 days (95% CI 3.57-8.27) higher than those without AMI. CONCLUSIONS: The study finds that the economic burden of AMI is substantial, for which effective prevention could result in significant health and productivity cost savings.

Impact of Race and Location of Residence on Statin Treatment Among Veterans With Type 2 Diabetes Mellitus.

Rural residence and ethnic-minority status are individually associated with increased cardiovascular (CV) mortality. Statin therapy is known to reduce the risk of cardiovascular mortality. Although ethnic disparities in statin treatment exist, the joint impact of urban/rural residence and race/ethnicity on statin prescribing is unclear. Veterans Health Administration (VHA) and Centers for Medicare and Medicaid data were used to perform a longitudinal study of Veterans with Type 2 diabetes mellitus from 2007 to 2016. Mixed effects logistic regression with a random intercept was used to model the longitudinal association between the primary exposure (race/ethnicity and residence) and statin prescribing. After adjusting for covariates, non-Hispanic White (NHW)-Rural Veterans were 7% (odds ratio [OR] = 1.07; confidence interval [CI] 1.05 to 1.08), non-Hispanic Black (NHB)-Rural Veterans were 4% (OR 1.04; CI 1.00 to 1.08), and Hispanic-Urban Veterans were 20% (OR 1.20; CI 1.17 to 1.23) more likely to be prescribed statins versus NHW-Urban Veterans; whereas, NHB-Urban Veterans were 14% (OR 0.86; CI 0.85 to 0.55) and Hispanic-Rural Veterans were 10% (OR 0.90; CI 0.85 to 0.96) less likely. When disability and dual use were removed from the full model, compared with NHW-Urban, the odds of statin prescribing in NHW-Rural Veterans remained unchanged (OR 1.06; CI 1.04 to 1.07) whereas the odds of statin prescribing in all other groups were higher. In conclusion, NHB-Urban and Hispanic-Rural Veterans had lower odds of statin prescribing versus NHW-Urban Veterans; whereas NHW-Rural, NHB-Rural and Hispanic-Urban Veterans had higher odds. The findings in ethnic-minorities changed when we accounted for markers of VHA care (i.e., disability, dual use) showing that these individuals are more likely to receive statins when they receive more VHA care.

Racial/Ethnic Differences in Glycemic Control in Older Adults with Type 2 Diabetes: United States 2003-2014.

The aim of this study was to determine whether racial differences in HbA1c persist in older adults (≥65 years) living with type 2 diabetes. Data from The National Health and Nutrition Examination Survey (NHANES) 2003-2014 were used to examine the association between HbA1c and older adults (≥65 years) over time. Compared to non-Hispanic Whites, Mexican Americans had the greatest difference in average HbA1c among minority groups, followed by those with unspecified/mixed ethnicities and non-Hispanic Blacks. In the adjusted linear model, racial minorities had a statistically significant relationship with HbA1c. There was no relationship between HbA1c and older age and insulin use. Trends in mean HbA1c over time increased for non-Hispanic Blacks and Mexican Americans and decreased for non-Hispanic Whites. The findings suggest that racial differences in HbA1c persist into older age and compared to non-Hispanic Whites, non-Hispanic Blacks and Mexican Americans are at an increased risk of morbidity, mortality, and disability due to high HbA1c. Furthermore, alternate measures of glycemic control may be needed to screen and manage T2DM in racial minorities.

A contemporary and comprehensive analysis of the costs of stroke in the United States.

BACKGROUND: While several studies have determined direct costs associated with stroke there is a paucity of research involving indirect costs, especially in younger patients. AIM: Perform a cost of illness analysis for ischemic and non-traumatic hemorrhagic stroke in the US involving both direct and indirect costs in all age groups. METHODS: Nationally representative data was obtained from the Medical Expenditure Panel Survey (2003-2014). Subjects were dichotomized based on reported history of stroke. Two-part econometric models were used to estimate the adjusted incremental direct expenditure for patients with stroke. We used generalized linear model with family gamma, log link for the adjusted analysis of annual wage, a negative binomial regression model for the adjusted analysis of missed-work day, and a logistic regression model to estimate the probability of full-year employment. Loss of productivity due to premature death was computed using Present-Value of one life and annual number of deaths from 2014 National Vital Statistics. All costs are represented in 2016 US-dollar values. RESULTS: Out of 253,235,052 participants, 8,101,159 (3.2%) reported history of stroke. Weighted samples of 10,155 stroke participants and 314,694 control group were compared. Adjusted annual direct costs for each stroke participant was $4317 (95% CI: $3828-$4807) greater than control resulting in a net $38 billion incremental expenditure. Based on salary difference, missed workdays, and mortality, indirect cost from under-employment was $38.1 billion and from premature mortality was $30.4 billion. CONCLUSION: Total aggregate of $103.5 billion expenditure was incurred with 66% being from indirect costs based on 2016 US-dollar values.

Racial Differences in Mechanical Thrombectomy Utilization for Ischemic Stroke in the United States.

Background: Compared with non-Hispanic Whites (NHW), racial-ethnic minorities bear a disproportionate burden of stroke and receive fewer evidence-based stroke care processes and treatments. Since 2015, mechanical thrombectomy (MT) has become standard of care for acute ischemic stroke (AIS) patients with proximal anterior circulation large vessel occlusion (LVO). Objectives: Our objectives were to: assess recent trends in nationwide MT utilization among patients with AIS; determine if there were racial differences; and identify what factors were associated with such differences. Methods: We performed a retrospective cohort study using nationally representative data of a non-institutionalized population sample from 2006 to 2014 obtained from the Nationwide Inpatient Sample (NIS). We identified a total of 889,309 observations of AIS, of which there were 5,256 MT observations. Results: In the fully adjusted model, rate of thrombectomy utilization was significantly lower in African Americans (AA) (OR .67, CI .58-.76, P<.001) compared with NHW and Hispanics (OR .94, CI .78-1.13, P=.5). Conclusion: We found a significant disparity in MT utilization for AA compared with NHW and Hispanics. More work is needed to understand the drivers of this racial disparity in stroke treatment.