Disparities in Outcomes of Hospitalizations Due to Multiple Myeloma: A Nationwide Comparison.

Background With the advent of novel treatments, there is a declining trend in the multiple myeloma (MM) mortality rate with an increasing hospitalization rate. However, there is limited population-based data on trends and outcomes of hospitalizations due to MM in the United States (US). Methods We analyzed the publicly available Nationwide Inpatient Sample (NIS) from 2007 to 2017 to identify MM hospitalizations. Results Hospitalizations for MM increased from 17,100 (8.71%) in 2007 to 19,490 (9.92%) in 2017. The in-hospital mortality rate declined from 8.4% in 2007 to 4.9% in 2017 (P <0.001) and discharge to facilities decreased from 20.4% in 2007 to 17.4% in 2017 (P <0.001). The odds of in-hospital mortality were higher with increasing age (odds ratio (OR): 1.46; 95% confidence interval (CI): 1.38 -1.54; P <0.0001), pneumonia (OR: 4.18; 95% CI: 3.63 - 4.81, P <0.0001), septicemia (OR: 2.50; 95% CI: 2.22 - 2.82; P <0.0001), renal failure (OR: 1.48; 95% CI: 1.34 -1.64; P <0.0001), uninsured/self-pay insurance status (OR: 2.69; 95% CI: 2.18 - 3.3; P <0.0001), rural hospital (OR: 2.26; 95% CI: 1.88 -2.72; P<0.0001), and urban-non-teaching hospitals (OR: 1.38; 95% CI: 1.23 - 1.56; P <0.0001). Also, increasing age (OR: 1.14; 95% CI: 1.11-1.18, P <0.0001), Black race (OR: 1.12; 95% CI: 1.02-1.23, P <0.0001), and multiple comorbidities were associated with higher disability. Conclusion Hospitalizations for MM continued to increase, whereas in-hospital mortality continued to decrease. Advanced age, sepsis, pneumonia, and renal failure were associated with higher odds of mortality in MM patients.

Trends and outcomes of peptic ulcer disease in patients with cirrhosis.

BACKGROUND: Peptic ulcer disease (PUD) is more prevalent in cirrhotic patients and it has been associated with poor outcomes. However, there are no population-based studies from the United States (U.S.) that have investigated this association. Our study aims to estimate the incidence trends, predictors, and outcomes PUD patients with underlying cirrhosis. METHODS: We analyzed Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project (HCUP) data for years 2002-2014. Adult hospitalizations due to PUD were identified by previously validated ICD-9-CM codes as the primary diagnosis. Cirrhosis was also identified with presence of ICD-9-CM codes in secondary diagnosis fields. We analyzed trends and predictors of PUD in cirrhotic patients and utilized multivariate regression models to estimate the impact of cirrhosis on PUD outcomes. RESULTS: Between the years 2002-2014, there were 1,433,270 adult hospitalizations with a primary diagnosis of PUD, out of which 70,007 (4.88%) had cirrhosis as a concurrent diagnosis. There was a significant increase in the proportion of hospitalizations with a concurrent diagnosis of cirrhosis, from 3.9% in 2002 to 6.6% in 2014 (p < 0.001). In an adjusted multivariable analysis, in-hospital mortality was significantly higher in hospitalizations of PUD with cirrhosis (odd ratio [OR] 1.78; 95% confidence interval [CI] 1.63-1.97; P < 0.001), however, there was no difference in the discharge to facility (OR 1.00; 95%CI 0.94 - 1.07; P = 0.81). Moreover, length of stay (LOS) was also higher (6 days vs. 4 days, P < 0.001) among PUD with cirrhosis. Increasing age and comorbidities were associated with higher odds of in-hospital mortality among PUD patients with cirrhosis. CONCLUSION: Our study shows that there is an increased hospital burden as well as poor outcomes in terms of higher in-hospital mortality among hospitalized PUD patients with cirrhosis. Further studies are warranted for better risk stratification and improvement of outcomes.

Healthful and less-healthful foods and drinks from storefront and non-storefront businesses: implications for 'food deserts', 'food swamps' and food-source disparities.

OBJECTIVE: Conceptualisations of 'food deserts' (areas lacking healthful food/drink) and 'food swamps' (areas overwhelm by less-healthful fare) may be both inaccurate and incomplete. Our objective was to more accurately and completely characterise food/drink availability in urban areas. DESIGN: Cross-sectional assessment of select healthful and less-healthful food/drink offerings from storefront businesses (stores, restaurants) and non-storefront businesses (street vendors). SETTING: Two areas of New York City: the Bronx (higher-poverty, mostly minority) and the Upper East Side (UES; wealthier, predominantly white). PARTICIPANTS: All businesses on 63 street segments in the Bronx (n 662) and on 46 street segments in the UES (n 330). RESULTS: Greater percentages of businesses offered any, any healthful, and only less-healthful food/drink in the Bronx (42·0 %, 37·5 %, 4·4 %, respectively) than in the UES (30 %, 27·9 %, 2·1 %, respectively). Differences were driven mostly by businesses (e.g. newsstands, gyms, laundromats) not primarily focused on selling food/drink - 'other storefront businesses' (OSBs). OSBs accounted for 36·0 % of all food/drink-offering businesses in the Bronx (more numerous than restaurants or so-called 'food stores') and 18·2 % in the UES (more numerous than 'food stores'). Differences also related to street vendors in both the Bronx and the UES. If street vendors and OSBs were not captured, the missed percentages of street segments offering food/drink would be 14·5 % in the Bronx and 21·9 % in the UES. CONCLUSIONS: Of businesses offering food/drink in communities, OSBs and street vendors can represent substantial percentages. Focusing on only 'food stores' and restaurants may miss or mischaracterise 'food deserts', 'food swamps', and food/drink-source disparities between communities.

Government data v. ground observation for food-environment assessment: businesses missed and misreported by city and state inspection records.

OBJECTIVE: To assess the accuracy of government inspection records, relative to ground observation, for identifying businesses offering foods/drinks. DESIGN: Agreement between city and state inspection records v. ground observations at two levels: businesses and street segments. Agreement could be 'strict' (by business name, e.g. 'Rizzo's') or 'lenient' (by business type, e.g. 'pizzeria'); using sensitivity and positive predictive value (PPV) for businesses and using sensitivity, PPV, specificity and negative predictive value (NPV) for street segments. SETTING: The Bronx and the Upper East Side (UES), New York City, USA. PARTICIPANTS: All food/drink-offering businesses on sampled street segments (n 154 in the Bronx, n 51 in the UES). RESULTS: By 'strict' criteria, sensitivity and PPV of government records for food/drink-offering businesses were 0·37 and 0·57 in the Bronx; 0·58 and 0·60 in the UES. 'Lenient' values were 0·40 and 0·62 in the Bronx; 0·60 and 0·62 in the UES. Sensitivity, PPV, specificity and NPV of government records for street segments having food/drink-offering businesses were 0·66, 0·73, 0·84 and 0·79 in the Bronx; 0·79, 0·92, 0·67, and 0·40 in the UES. In both areas, agreement varied by business category: restaurants; 'food stores'; and government-recognized other storefront businesses ('gov. OSB', i.e. dollar stores, gas stations, pharmacies). Additional business categories - 'other OSB' (barbers, laundromats, newsstands, etc.) and street vendors - were absent from government records; together, they represented 28·4 % of all food/drink-offering businesses in the Bronx, 22·2 % in the UES ('other OSB' and street vendors were sources of both healthful and less-healthful foods/drinks in both areas). CONCLUSIONS: Government records frequently miss or misrepresent businesses offering foods/drinks, suggesting caveats for food-environment assessments using such records.

Temporal Trends of Pediatric Hospitalizations with Acute Disseminated Encephalomyelitis in the United States: An Analysis from 2006 to 2014 using National Inpatient Sample.

OBJECTIVE: To determine the temporal trends in the epidemiology of acute disseminated encephalomyelitis (ADEM) and hospitalization outcomes in the US from 2006 through 2014. STUDY DESIGN: Pediatric (≤18 years of age) hospitalizations with ADEM discharge diagnosis were identified from the National (Nationwide) Inpatient Sample (NIS) for years 2006 through 2014. Trends in the incidence of ADEM with respect to age, sex, race, and region were examined. Outcomes of ADEM in terms of mortality, length of stay (LOS), cost of hospitalization, and seasonal variation were analyzed. NIS includes sampling weight. These weights were used to generate national estimates. P value of < .05 was considered significant. RESULTS: Overall incidence of ADEM associated pediatric hospitalizations from 2006 through 2014 was 0.5 per 100 000 population. Between 2006 through 2008 and 2012 through 2014, the incidence of ADEM increased from 0.4 to 0.6 per 100 000 (P-trend <.001). Black and Hispanic children had a significantly increased incidence of ADEM during the study period (0.2-0.5 per 100 000 population). There was no sex preponderance and 67% of ADEM hospitalizations were in patients <9 years old. From 2006 through 2008 to 2012 through 2014 (1.1%-1.5%; P-trend 0.07) and median LOS (4.8-5.5 days; Ptrend = .3) remained stable. However, median inflation adjusted cost increased from $11 594 in 2006 through 2008 to $16 193 in 2012 through 2014 (Ptrend = .002). CONCLUSION: In this large nationwide cohort of ADEM hospitalizations, the incidence of ADEM increased during the study period. Mortality and LOS have remained stable over time, but inflation adjusted cost of hospitalizations increased.

Nationwide Trends in Hospital Outcomes and Utilization After Lower Limb Revascularization in Patients on Hemodialysis.

OBJECTIVES: This study aimed to describe the temporal trends and outcomes of endovascular and surgical revascularization in a large, nationally representative sample of patients with end-stage renal disease on hemodialysis hospitalized for peripheral artery disease (PAD). BACKGROUND: PAD is prevalent among patients with end-stage renal disease on hemodialysis and is associated with significant morbidity and mortality. There is a paucity of information on trends in endovascular and surgical revascularization and post-procedure outcomes in this population. METHODS: We used the Nationwide Inpatient Sample (2002 to 2012) to identify hemodialysis patients undergoing endovascular or surgical procedures for PAD using diagnostic and procedural codes. We compared trends in amputation, post-procedure complications, mortality, length of stay, and costs between the 2 groups using trend tests and logistic regression. RESULTS: There were 77,049 endovascular and 29,556 surgical procedures for PAD in hemodialysis patients. Trend analysis showed that endovascular procedures increased by nearly 3-fold, whereas there was a reciprocal decrease in surgical revascularization. Post-procedure complication rates were relatively stable in persons undergoing endovascular procedures but nearly doubled in those undergoing surgery. Surgery was associated with 1.8 times adjusted odds (95% confidence interval: 1.60 to 2.02) for complications and 1.6 times the adjusted odds for amputations (95% confidence interval: 1.40 to 1.75) but had similar mortality (adjusted odds ratio: 1.05; 95% confidence interval: 0.85 to 1.29) compared with endovascular procedures. Length of stay for endovascular procedures remained stable, whereas a decrease was seen for surgical procedures. Overall costs increased marginally for both procedures. CONCLUSIONS: Rates of endovascular procedures have increased, whereas those of surgeries have decreased. Surgical revascularization is associated with higher odds of overall complications. Further prospective studies and clinical trials are required to analyze the relationship between the severity of PAD and the revascularization strategy chosen.

Epidemiology of inpatient stay in Parkinson's disease in the United States: Insights from the Nationwide Inpatient Sample.

The total number of people living with Parkinson's disease (PD) worldwide is expected to double by 2030. The risk factors for emergency department visits in PD patients have been described before, however, there is limited data on inpatient hospitalizations of PD patients. We derived our study cohort from the Nationwide Inpatient Sample (NIS) database from 2002-2011. The NIS is a stratified 20% sample of discharges from all U.S. hospitals. We extracted causes of hospitalization using International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes and calculated inpatient mortality, length of stay and cost. Further, the significance of trends over 10 years was assessed. A total of 3,015,645 (weighted) admissions of PD patients were documented from 2002-2011. Pneumonia, urinary tract infection (UTI), septicemia and aspiration pneumonitis were the most common causes of admission, of which incidence of sepsis and UTI was trending up. Of all causes, 3.9% of the admissions resulted in inpatient mortality. Inpatient mortality for PD patients decreased from 4.9% in 2002 to 3.3% in 2011 (p<0.001). The median length of stay has also steadily declined from 3.6days in 2002 to 2.3days in 2011. However, the inflation-adjusted cost of care has been steadily rising, from $22,250 per hospitalization in 2002 to $37,942 in 2011. We conclude that the epidemiology of inpatient admissions in PD has changed significantly over the last decade. Our study underscores the need for future, in-depth prospective studies to explore this changing disease spectrum to design preventive measures and targeted interventions.

A Nationwide Analysis of Outcomes of Weekend Admissions for Intracerebral Hemorrhage Shows Disparities Based on Hospital Teaching Status.

BACKGROUND AND PURPOSE: With the "weekend effect" being well described, the Brain Attack Coalition released a set of "best practice" guidelines in 2005, with the goal to uniformly provide standard of care to patients with stroke. We attempted to define a "weekend effect" in outcomes among patients with intracranial hemorrhage (ICH) over the last decade, utilizing the Nationwide Inpatient Sample (NIS) data. We also attempted to analyze the trend of such an effect. MATERIALS AND METHODS: We determined the association of ICH weekend admissions with hospital outcomes including mortality, adverse discharge, length of stay, and cost compared to weekday admissions using multivariable logistic regression. We extracted our study cohort from the NIS, the largest all-payer data set in the United States. RESULTS: Of 485 329 ICH admissions from 2002 to 2011, 27.5% were weekend admissions. Overall, weekend admissions were associated with 11% higher odds of in-hospital mortality. When analyzed in 3-year groups, excess mortality of weekend admissions showed temporal decline. There was higher mortality with weekend admissions in nonteaching hospitals persisted (odds ratios 1.16, 1.13, and 1.09, respectively, for 3-year subgroups). Patients admitted during weekends were also 9% more likely to have an adverse discharge (odds ratio 1.09; 95% confidence interval: 1.07-1.11; P < .001) with no variation by hospital status. There was no effect of a weekend admission on either length of stay or cost of care. CONCLUSION: Nontraumatic ICH admissions on weekends have higher in-hospital mortality and adverse discharge. This demonstrates need for in-depth review for elucidating this discrepancy and stricter adherence to standard-of-care guidelines to ensure uniform care.

Impact of Glycoprotein IIb/IIIa Inhibitors Use on Outcomes After Lower Extremity Endovascular Interventions From Nationwide Inpatient Sample (2006-2011).

OBJECTIVE: The aim of our study was to study the impact of glycoprotein IIb/IIIa inhibitors (GPI) on in-hospital outcomes. BACKGROUND: There is paucity of data regarding the impact of GPI on the outcomes following peripheral endovascular interventions. METHODS: The study cohort was derived from Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database between the years 2006 and 2011. Peripheral endovascular interventions and GPI utilization were identified using appropriate ICD-9 Diagnostic and procedural codes. Two-level hierarchical multivariate mixed models were created. The study outcomes were: primary (in-hospital mortality and amputation studied separately) and secondary (composite of in-hospital mortality and postprocedural complications). Hospitalization costs were also assessed. RESULTS: GPI utilization (OR, 95% CI, P-value) was independently predictive of lower amputation rates (0.36, 0.27-0.49, <0.001). There was no significant difference in terms of in-hospital mortality (0.59, 0.31-1.14, P 0.117), although GPI use predicted worse secondary outcomes (1.23, 1.03-1.47, 0.023). Following propensity matching, the amputation rate was lower (3.2% vs. 8%, P < 0.001), while hospitalization costs were higher in the cohort that received GPI ($21,091 ± 404 vs. 19,407 ± 133, P < 0.001). CONCLUSIONS: Multivariate analysis revealed GPI use in peripheral endovascular interventions to be suggestive of an increase in composite end-point of in-hospital mortality and postprocedural complications, no impact on in-hospital mortality alone, significantly lower rate of amputation, and increase in hospitalization costs. © 2016 Wiley Periodicals, Inc.

Gender, Race, and Health Insurance Status in Patients Undergoing Catheter Ablation for Atrial Fibrillation.

Catheter ablation for atrial fibrillation (AF) has emerged as a popular procedure. The purpose of this study was to examine whether there exist differences or disparities in ablation utilization across gender, socioeconomic class, insurance, or race. Using the Nationwide Inpatient Sample (2000 to 2012), we identified adults hospitalized with a principal diagnosis of AF by ICD 9 code 427.31 who had catheter ablation (ICD 9 code-37.34). We stratified patients by race, insurance status, age, gender, and hospital characteristics. A hierarchical multivariate mixed-effect model was created to identify the independent predictors of AF ablation. Among an estimated total of 3,508,122 patients (extrapolated from 20% Nationwide Inpatient Sample) hospitalized with a diagnosis of AF in the United States from the year 2000 to 2012, 102,469 patients (2.9%) underwent catheter ablations. The number of ablations was increased by 940%, from 1,439 in 2000 to 15,090 in 2012. There were significant differences according to gender, race, and health insurance status, which persisted even after adjustment for other risk factors. Female gender (0.83 [95% CI 0.79 to 0.87; p <0.001]), black (0.49 [95% CI 0.44 to 0.55; p <0.001]), and Hispanic race (0.64 [95% CI 0.56 to 0.72; p <0.001]) were associated with lower likelihoods of undergoing an AF ablation. Medicare (0.93, 0.88 to 0.98, <0.001) or Medicaid (0.67, 0.59 to 0.76, <0.001) coverage and uninsured patients (0.55, 0.49 to 0.62, <0.001) also had lower rates of AF ablation compared to patients with private insurance. In conclusion we found differences in utilization of catheter ablation for AF based on gender, race, and insurance status that persisted over time.

Coronary Atherectomy in the United States (from a Nationwide Inpatient Sample).

Contemporary real-world data on clinical outcomes after utilization of coronary atherectomy are sparse. The study cohort was derived from Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from year 2012. Percutaneous coronary interventions including atherectomy were identified using appropriate International Classification of Diseases, 9th Revision diagnostic and procedural codes. Two-level hierarchical multivariate mixed models were created. The primary outcome was a composite of in-hospital mortality and periprocedural complications; the secondary outcome was in-hospital mortality. Hospitalization costs were also assessed. A total of 107,131 procedures were identified in 2012. Multivariate analysis revealed that atherectomy utilization was independently predictive of greater primary composite outcome of in-hospital mortality and complications (odds ratio 1.34, 95% confidence interval 1.22 to 1.47, p <0.001) but was not associated with any significant difference in terms of in-hospital mortality alone (odds ratio 1.22, 95% confidence interval 0.99 to 1.52, p 0.063). In the propensity-matched cohort, atherectomy utilization was again associated with a higher rate of complications (12.88% vs 10.99%, p = 0.001), in-hospital mortality +a ny complication (13.69% vs 11.91%, p = 0.003) with a nonsignificant difference in terms of in-hospital mortality alone (3.45% vs 2.88%, p = 0.063) and higher hospitalization costs ($25,341 ± 353 vs $21,984 ± 87, p <0.001). Atherectomy utilization during percutaneous coronary intervention is associated with a higher rate of postprocedural complications without any significant impact on in-hospital mortality.

A National Perspective of Do-Not-Resuscitate Order Utilization Predictors in Intracerebral Hemorrhage.

Nontraumatic intracerebral hemorrhage (ICH) is associated with substantial morbidity and mortality. Do-not-resuscitate (DNR) orders are linked to poorer outcomes in patients with ICH, possibly due to less active management. Demographic, regional, and social factors, not related to ICH severity, have not been adequately looked at as significant predictors of DNR utilization. We reviewed the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database in 2011 for adult ICH admissions and DNR status. We generated hierarchical 2-level multivariate regression models to estimate adjusted odds ratios. We analyzed 25 768 ICH hospitalizations, 18% of which (4620 hospitalizations) had DNR orders, corresponding to national estimates of 126 254 and 22 668, respectively. In multivariable regression, female gender, white or Hispanic/Latino ethnicity, no insurance coverage, and teaching hospitals were significantly associated with increased DNR utilization after adjusting for confounders. There was also significantly more interhospital variability in the lowest quartile of hospital volume. In conclusion, demographic factors and insurance status are significantly associated with increased DNR utilization, with more individual hospital variability in low-volume hospitals. The reasons for this are likely qualitative and linked to patient, provider, and hospital practices.

Gender, Racial, and Health Insurance Differences in the Trend of Implantable Cardioverter-Defibrillator (ICD) Utilization: A United States Experience Over the Last Decade.

Prior studies have highlighted disparities in cardiac lifesaving procedure utilization, particularly among women and in minorities. Although there has been a significant increase in implantable cardioverter-defibrillator (ICD) insertion, socioeconomic disparities still exist in the trend of ICD utilization. With the use of the Nationwide Inpatient Sample from 2003 through 2011, we identified subjects with ICD insertion (procedure code 37.94) and cardiac resynchronization defibrillator (procedure code 00.50, 00.51) as codified by the International Classification of Diseases, Ninth Revision, Clinical Modification. Overall, 1 020 076 ICDs were implanted in the United States from 2003 to 2011. We observed an initial increase in ICD utilization by 51%, from 95 062 in 2003 to 143 262 in 2006, followed by a more recent decline. The majority of ICDs were implanted in men age ≥65 years. Implantation of ICDs was 2.5× more common in men than in women (402 per million vs 163 per million). Approximately 95% of the ICDs were implanted in insured patients, and 5% were used in the uninsured population. There has been a significant increase in ICD implantation in blacks, from 162 per million in 2003 to 291 per million in 2011. We found a significant difference in the volume of ICD implants between the insured and the uninsured patient populations. Racial disparities have narrowed significantly in comparison with those noted in earlier studies and are now more reflective of the population demographics at large. On the other hand, significant gender disparities continue to exist.

Incidence, Trends, and Outcomes of Cerebral Edema Among Children With Diabetic Ketoacidosis in the United States.

INTRODUCTION: There are limited data regarding the incidence, trends, and outcomes of cerebral edema among patients with diabetic ketoacidosis (DKA). METHODS: NIS database was used from year 2002 to 2012. Cases with primary diagnosis of DKA were identified using International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9 CM) code 250.1 x. Cerebral edema patients were identified using ICD-9 CM code 348.5. We compared the baseline characteristics of both groups to estimate differences using the χ(2) test, Student's t test, Wilcoxon rank-sum test, and survey regression depending on the distributions of variables. For trend analysis, the χ(2) test of trend for proportions was used using the Cochrane Armitage test via the "trend" command in Statistical Analysis Software (SAS). Multivariate odds ratios were calculated. P value for <0.05 was considered as significant for all analysis. RESULTS: In all, 205 (weighted n = 974) cases of cerebral edema were identified among 52 049 (weighted n = 246 925) DKA patients, which estimates the incidence of cerebral edema at 0.39%. Trends of incidence of developing cerebral edema increased almost 2 times, from 0.34 in 2002 to 0.64 in 2012 (P < 0.001). Univariate analysis showed that both length of stay (LOS; 3 vs 2; P < 0.001) and cost of hospitalization ($10 530 vs $3953; P < 0.001) were statistically higher among those who developed cerebral edema. CONCLUSION: Our study shows that over the study period, trend in incidence of cerebral edema among DKA patients has increased. Patients with cerebral edema were found to have longer LOS and higher cost of hospitalization.

Intravascular Ultrasound in Lower Extremity Peripheral Vascular Interventions: Variation in Utilization and Impact on In-Hospital Outcomes From the Nationwide Inpatient Sample (2006-2011).

PURPOSE: To examine the impact of intravascular ultrasound (IVUS) utilization during lower limb endovascular interventions as regards postprocedural complications and amputation. METHODS: The study cohort was derived from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database between the years 2006 and 2011. Peripheral endovascular interventions were identified using appropriate ICD-9 procedure codes. Two-level hierarchical multivariate mixed models were created. The co-primary outcomes were in-hospital mortality and amputation; the secondary outcome was postprocedural complications. Model results are given as the odds ratio (OR) and 95% confidence interval (CI). Hospitalization costs were also assessed. RESULTS: Overall, among the 92,714 patients extracted from the database during the observation period, IVUS was used in 1299 (1.4%) patients. IVUS utilization during lower extremity peripheral vascular procedures was independently predictive of a lower rate of postprocedural complications (OR 0.80, 95% CI 0.66 to 0.99, p=0.037) as well as lower amputation rates (OR 0.59, 95% CI 0.45 to 0.77, p<0.001) without any significant impact on in-hospital mortality. Multivariate analysis also revealed IVUS utilization to be predictive of a nonsignificant increase in hospitalization costs ($1333, 95% CI -$167 to +$2833, p=0.082). CONCLUSION: IVUS use during lower limb endovascular interventions is predictive of lower postprocedural complication and amputation rates with a nonsignificant increase in hospitalization costs.

Variability in utilization of drug eluting stents in United States: Insights from nationwide inpatient sample.

OBJECTIVES: We studied the trends and predictors of drug eluting stent (DES) utilization from 2006 to 2011 to further expound the inter-hospital variability in their utilization. BACKGROUND: We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) between 2006 and 2011 using ICD-9-CM procedure code, 36.06 (bare metal stent) or 36.07 (drug eluting stents) for Percutaneous Coronary Intervention (PCI). Annual hospital volume was calculated using unique identification numbers and divided into quartiles for analysis. METHODS AND RESULTS: We built a hierarchical two level model adjusted for multiple confounding factors, with hospital ID incorporated as random effects in the model. About 665,804 procedures (weighted n = 3,277,884) were analyzed. Safety concerns arising in 2006 reduced utilization DES from 90% of all PCIs performed in 2006 to a nadir of 69% in 2008 followed by increase (76% of all stents in 2009) and plateau (75% in 2011). Significant between-hospital variation was noted in DES utilization irrespective of patient or hospital characteristics. Independent patient level predictors of DES were (OR, 95% CI, P-value) age (0.99, 0.98-0.99, <0.001), female(1.12, 1.09-1.15, <0.001), acute myocardial infarction(0.75, 0.71-0.79, <0.001), shock (0.53, 0.49-0.58, <0.001), Charlson Co-morbidity index (0.81,0.77-0.86, <0.001), private insurance/HMO (1.27, 1.20-1.34, <0.001), and elective admission (1.16, 1.05-1.29, <0.001). Highest quartile hospital (1.64, 1.25-2.16, <0.001) volume was associated with higher DES placement. CONCLUSION: There is significant between-hospital variation in DES utilization and a higher annual hospital volume is associated with higher utilization rate of DES. © 2015 Wiley Periodicals, Inc.

Transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with cirrhosis.

OBJECTIVES: To compare the in-hospital outcomes in cirrhosis patients undergoing transcatheter aortic valve replacement (TAVR) versus those undergoing surgical aortic valve replacement (SAVR). BACKGROUND: Over the last 10 years, TAVR has emerged as a therapeutic option for treating severe aortic stenosis in high-risk patients. Cirrhosis patients have a high risk of operative morbidity and mortality while undergoing cardiac surgery. This study's hypothesis was that TAVR is a safer alternative compared to SAVR in cirrhosis patients. METHODS: The study population was derived from the National Inpatient Sample (NIS) for the years 2011-2012 using ICD-9-CM procedure codes 35.21 and 35.22 for SAVR, and 35.05 and 35.06 for TAVR. Patients <50 years of age and those who concomitantly underwent other valvular procedures were excluded. ICD-9-CM diagnosis codes were used to identify patients with liver cirrhosis, portal hypertension, and esophageal varices. Using propensity score matching, two matched cohorts were derived in which the outcomes were compared using appropriate statistical tests. RESULTS: There were 30 patients in the SAVR and TAVR group each. Compared to the TAVR group, the patients in SAVR group had significantly higher rate of transfusion of whole blood or blood products (p = 0.037), longer mean postprocedural length of stay (p = 0.006), and nonsignificantly higher mean cost of hospitalization (p = 0.2), any complications rate (p = 0.09), and liver complications rate (p = 0.4). In-hospital mortality rate was same in the both the groups. No patients in the TAVR group required open-heart surgery or cardiopulmonary bypass. CONCLUSION: TAVR could be a viable option for aortic valve replacement in cirrhosis patients.

Impact of Hospital Volume on Outcomes of Endovascular Stenting for Adult Aortic Coarctation.

Use of transcatheter endovascular stenting has been increasing in the treatment of coarctation of aorta (CoA). The present study was undertaken on adults with CoA who underwent stent placement from 2000 to 2011 to analyze the relation of hospital volumes to the outcomes of stenting in adults with CoA. It was a retrospective study based on Healthcare Cost and Utilization Project's Nationwide Inpatient Sample (NIS) database from 2000 to 2011 and identified subjects using the International Classification of Diseases, Ninth Revision, Clinical Modification procedure code of 747.10 (CoA). Annual hospital volume was calculated using unique hospital identifiers. Weights provided by the Nationwide Inpatient Sample were used to generate national estimates. A total of 105 (weighted 521) subjects were identified with International Classification of Diseases, Ninth Revision, code of 39.90 (Endovascular stent). Hospital volumes were divided into tertiles. We compared the highest tertile (≥3 procedures annually) with other tertiles (<3 procedure annually). The composite outcomes of the analysis were procedure-related complications, length of stay (LOS), and cost in relation to the hospital volume. No inhospital death was reported in either group. Hospitals with ≥3 procedures annually had significantly lower incidence of complications (9.5% vs 23.0%) compared to the hospitals with <3 procedures annually (p-value 0.002). Similar results were obtained after multivariate regression analysis in relation to hospital volume. Shorter LOS and lower cost were observed with annual hospital volume of ≥3 procedures. In conclusion, stenting adults for CoA is remarkably safe, and the outcomes of the procedure have improved in centers with annual hospital volume of ≥3 procedures. There is also decreasing trend of procedure-related complications, shorter LOS, and lower costs compared to centers with annual volume <3 procedures.

Utilization of catheter-directed thrombolysis in pulmonary embolism and outcome difference between systemic thrombolysis and catheter-directed thrombolysis.

OBJECTIVE: The aim of the study was to assess the utilization of catheter-directed thrombolysis (CDT) and its comparative effectiveness against systemic thrombolysis in acute pulmonary embolism (PE). BACKGROUND: Contemporary real world data regarding utilization and outcomes comparing systemic thrombolysis with CDT for PE is sparse. METHODS: We queried the Nationwide Inpatient Sample from 2010 to 2012 using the ICD-9-CM diagnosis code 415.11, 415.13, and 415.19 for acute PE. We used propensity score analysis to compare outcomes between systemic thrombolysis and CDT. Primary outcome was in-hospital mortality. Secondary outcome was combined in-hospital mortality and intracranial hemorrhage (ICH). RESULTS: Out of 110,731 patients hospitalized with PE, we identified 1,521 patients treated with thrombolysis, of which 1,169 patients received systemic thrombolysis and 352 patients received CDT. After propensity-matched comparison, primary and secondary outcomes were significantly lower in the CDT group compared to systemic thrombolysis (21.81% vs. 13.36%, OR 0.55, 95% CI 0.36-0.85, P value = 0.007) and (22.89% vs. 13.36%, OR 0.52, 95% CI 0.34-0.80, P value = 0.003), respectively. The median length of stay [7 days, interquartile range (IQR) (5-9 days) vs. 7 days, IQR (5-10 days), P = 0.17] was not significant between the two groups. The CDT group had higher cost of hospitalization [$17,218, IQR ($12,272-$23,906) vs. $23,799, IQR ($17,892-$35,338), P < 0.001]. Multivariate analysis identified increasing age, saddle PE, cardiopulmonary arrest, and Medicaid insurance as independent predictors of in-hospital mortality. CONCLUSIONS: CDT was associated with lower in-hospital mortality and combined in-hospital mortality and ICH.

Effect of Hospital Volume on Outcomes of Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is associated with a significant learning curve. There is paucity of data regarding the effect of hospital volume on outcomes after TAVI. This is a cross-sectional study based on Healthcare Cost and Utilization Project's Nationwide Inpatient Sample database of 2012. Subjects were identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes, 35.05 (Trans-femoral/Trans-aortic Replacement of Aortic Valve) and 35.06 (Trans-apical Replacement of Aortic Valve). Annual hospital TAVI volumes were calculated using unique identification numbers and then divided into quartiles. Multivariate logistic regression models were created. The primary outcome was inhospital mortality; secondary outcome was a composite of inhospital mortality and periprocedural complications. Length of stay (LOS) and cost of hospitalization were assessed. The study included 1,481 TAVIs (weighted n = 7,405). Overall inhospital mortality rate was 5.1%, postprocedural complication rate was 43.4%, median LOS was 6 days, and median cost of hospitalization was $51,975. Inhospital mortality rates decreased with increasing hospital TAVI volume with a rate of 6.4% for lowest volume hospitals (first quartile), 5.9% (second quartile), 5.2% (third quartile), and 2.8% for the highest volume TAVI hospitals (fourth quartile). Complication rates were significantly higher in hospitals with the lowest volume quartile (48.5%) compared to hospitals in the second (44.2%), third (39.7%), and fourth (41.5%) quartiles (p <0.001). Increasing hospital volume was independently predictive of shorter LOS and lower hospitalization costs. In conclusion, higher annual hospital volumes are significantly predictive of reduced postprocedural mortality, complications, shorter LOS, and lower hospitalization costs after TAVI.