Hospital Admissions from the Emergency Department and Subsequent Critical Care Interventions for Influenza during Pregnancy.

OBJECTIVE: The objectives of this study were to determine (1) whether obstetrical patients were more likely to be admitted from the emergency department (ED) for influenza compared with nonpregnant women, and (2) require critical care interventions once admitted. STUDY DESIGN: Using data from the 2006 to 2011 Nationwide Emergency Department Sample, ED encounters for influenza for women aged 15 to 54 years without underlying chronic medical conditions were identified. Women were categorized as pregnant or nonpregnant using billing codes. Multivariable log linear models were fit to evaluate the relative risk of admission from the ED and the risk of intensive care unit (ICU)-level interventions including mechanical ventilation and central monitoring with pregnancy status as the exposure of interest. Measures of association were described with adjusted risk ratios (aRRs) with 95% confidence intervals (CIs). RESULTS: We identified 15.9 million ED encounters for influenza of which 4% occurred among pregnant women. Pregnant patients with influenza were nearly three times as likely to be admitted as nonpregnant patients (aRR = 2.99, 95% CI: 2.94, 3.05). Once admitted, obstetric patients were at 72% higher risk of ICU-level interventions (aRR = 1.72, 95% CI: 1.61, 1.84). Of pregnant women admitted from the ED, 9.3% required ICU-level interventions such as mechanical ventilation or central monitoring. Older patients and those with Medicare were also at high risk of admission and ICU-level interventions (p < 0.01). CONCLUSION: Pregnancy confers three times the risk of admission from the ED for influenza and pregnant women are significantly more likely to require ICU-level medical interventions compared with women of similar age. These findings confirm the significant disease burden from influenza in the obstetric population and the public health importance of reducing infection risk. KEY POINTS: · Pregnancy confers three times the risk of admission from the ED for influenza.. · Pregnant women admitted with influenza are significantly more likely to require ICU-level care.. · Influenza represents a significant disease burden in the obstetric population.

Effect of frailty on postoperative readmissions and cost of care for ovarian cancer.

OBJECTIVES: Frailty, defined as loss of reserve and vulnerability to changes in health, affects many ovarian cancer patients who are planned to undergo surgery. The effect of frailty on postoperative readmissions in ovarian cancer patients remains poorly defined. We investigated the effect of frailty on unplanned readmission, morbidity, and mortality among patients undergoing surgery for ovarian cancer. STUDY DESIGN: Patients who underwent laparotomy for ovarian cancer between 2010 and 2014 were identified using the Nationwide Readmissions Database. Frailty was classified using the Johns Hopkins Adjusted Clinical Groups Frailty Diagnoses Indicators. Primary outcomes were divided into index admission (intensive level of care, mortality, non-routine discharge,) 30-days (readmission and mortality), and 90-days (readmission and mortality). Multivariable regression models were fit, adjusting for patient, hospital, and clinical factors. RESULTS: From 2010 to 2014, there were 76,441 inpatient laparotomies identified with a 6.1% frailty rate. Frailty was associated with an increased risk of intensive level of care (aRR = 1.76, 95% CI: 1.68, 1.85), non-routine discharge (aRR = 1.39, 95% CI: 1.33, 1.45), and inpatient mortality (aRR = 1.91, 95% CI: 1.63, 2.23) during the index admission. Frail patients were more likely to be readmitted within 90 days (aRR = 1.11, 95% CI: 1.04-1.18), sustain mortality during 90-day readmission (aRR = 1.31, 95% CI 1.01-1.69), and have longer and costlier index hospital stays. Hospital readmission costs did not differ significantly between frail and non-frail patients. CONCLUSIONS: Frailty affects postoperative outcomes in ovarian cancer patients and is associated with an increased rate of 90-day readmission and mortality among those who are readmitted. Gynecologic oncologists should screen for frailty and consider outcomes in frail ovarian cancer patients when counseling for surgery.

Fragmentation of postoperative care after surgical management of ovarian cancer at 30 days and 90 days.

BACKGROUND: Fragmentation of care, wherein a patient is discharged from an index hospital and undergoes an unexpected readmission to a nonindex hospital, is associated with increased risk of adverse outcomes. Fragmentation has not been well-characterized in ovarian cancer. OBJECTIVE: The objective of this study was to assess risk factors and outcomes that are associated with fragmentation of care among women who undergo surgical treatment of ovarian cancer. STUDY DESIGN: The Nationwide Readmission Database was used to identify all-cause 30-day and 90-day postoperative readmissions after surgical management of ovarian cancer from 2010-2014. Postoperative fragmentation was defined as readmission to a hospital other than the index hospital of the initial surgery. Multivariable regression analyses were used to identify predictors of fragmentation in both 30-day and 90-day readmissions. Similarly, multivariable models were developed to determine the association between fragmentation and death among women who were readmitted. RESULTS: A total of 10,445 patients (13.3%) were readmitted at 30 days, and 14,124 patients (18.0%) were readmitted at 90 days. Of these, there was a 20.8% and 25.7% rate of postoperative care fragmentation for 30-day and 90-day readmissions, respectively. Patient risk factors that were associated with fragmented postoperative care included Medicare insurance, lower income quartiles, and nonroutine discharge to facility. Hospital factors that were associated with decreased risk of fragmentation included operation at a metropolitan teaching hospital and performance of extended procedures. Cost and length of stay for the readmission were similar among those who had fragmented and nonfragmented readmissions at both 30 and 90 days. Although there was no association between death and fragmentation for patients who were readmitted within 30 days (odds ratio, 1.19; 95% confidence interval, 0.93-1.51), patients who had a fragmented readmission at 90 days were 22% more likely to die than those who were readmitted at 90 days to their index hospital (odds ratio, 1.22; 95% confidence interval, 1.00-1.49). CONCLUSION: Fragmentation of care is common in women with ovarian cancer who require postoperative readmission. Fragmented postoperative care is associated with an increased risk of death among women who are readmitted within 90 days of surgery.

Utilization and Outcomes of Sentinel Lymph Node Biopsy for Vulvar Cancer.

OBJECTIVE: To examine the use and predictors of sentinel node biopsy in women with vulvar cancer. METHODS: The Perspective database, an all-payer database that collects data from more than 500 hospitals, was used to perform a retrospective cohort study of women with vulvar cancer who underwent vulvectomy and lymph node assessment from 2006 to 2015. Multivariable models were used to determine factors associated with sentinel node biopsy. Length of stay and cost were compared between women who underwent sentinel node biopsy and lymphadenectomy. RESULTS: Among 2,273 women, sentinel node biopsy was utilized in 618 (27.2%) and 1,655 (72.8%) underwent inguinofemoral lymphadenectomy. Performance of sentinel node biopsy increased from 17.0% (95% confidence interval [CI] 12.0-22.0%) in 2006 to 39.1% (95% CI 27.1-51.0%) in 2015. In a multivariable model, women treated more recently were more likely to have undergone sentinel node biopsy, whereas women with more comorbidities and those treated at rural hospitals were less likely to have undergone the procedure. The median length of stay was shorter for those undergoing sentinel node biopsy (median 2 days, interquartile range 1-3) compared with women who underwent inguinofemoral lymphadenectomy (median 3 days, interquartile range 2-4). The cost of sentinel node biopsy was $7,599 (interquartile range $5,739-9,922) compared with $8,095 (interquartile range $5,917-11,281) for lymphadenectomy. CONCLUSION: The use of sentinel node biopsy for vulvar cancer has more than doubled since 2006. Sentinel lymph node biopsy is associated with a shorter hospital stay and decreased cost compared with inguinofemoral lymphadenectomy.

Risk-based ultrasound screening for thyroid cancer in obese patients is cost-effective.

BACKGROUND: A higher body mass index (BMI) is associated with more advanced stages of thyroid cancer. Screening obese patients for thyroid cancer has been proposed but has yet to be examined for cost-effectiveness. The objective of this study was to assess the cost-effectiveness of ultrasound (US) screening of obese patients for thyroid cancer. METHODS: A decision-tree model compared cost savings for the following: (i) base case scenario of an obese patient with thyroid nodule found by palpation, (ii) universal US screening of all obese patients, and (iii) risk-based US screening in obese patients. Risk-based screening consisted of patients who had at least one of four major identified risk factors for thyroid cancer (family history of thyroid cancer, radiation exposure, Hashimoto's thyroiditis, and/or elevated thyrotropin). Patients with nodules underwent established treatment and management guidelines. The model accounted for recurrence, complications, and long-term treatment/follow-up for five years. Outcome probabilities were identified from a literature review. Costs were estimated using a third-party payer perspective. Sensitivity analyses were performed to examine the impact of risk factor prevalence and US cost on the model. RESULTS: The resulted costs per patient were $210.73 in the base case scenario, $434.10 in the universal US screening arm, and $166.72 in the risk-based screening arm. Risk-based screening remained cost-effective until more than 14% of obese patients had risk factors and with a wide variation of US costs ($0-$1113). CONCLUSION: Risk-based US screening in selected obese patients with risk factors for thyroid cancer is cost-effective. Recommendations for screening this subgroup will result in cost savings and a likely decreased morbidity and mortality in this subpopulation with more aggressive disease.