Mortality and cost of post-cardiotomy extracorporeal support in the United States.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality. METHODS: We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality. RESULTS: There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% (n = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently. CONCLUSION: Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.

Evolving Cost-Quality Relationship in Pediatric Heart Surgery.

BACKGROUND: For the more than 40,000 children in the United States undergoing congenital heart surgery annually, the relationship between hospital quality and costs remains unclear. Prior studies report conflicting results and clinical outcomes have continued to improve over time. We examined a large contemporary cohort, aiming to better inform ongoing initiatives seeking to optimize health care value in this population. METHODS: Clinical information (The Society of Thoracic Surgeons Congenital Database) was merged with standardized cost data (Pediatric Health Information Systems) for children undergoing heart surgery from 2010 to 2015. In-hospital cost variability was analyzed using Bayesian hierarchical models adjusted for case-mix. Quality metrics examined included in-hospital mortality, postoperative complications, postoperative length of stay (PLOS), and a composite. RESULTS: Overall, 32 hospitals (n = 45,315 patients) were included. Median adjusted cost per case varied across hospitals from $67,700 to $51,200 in the high vs low cost tertile (ratio 1.32; 95% credible interval, 1.29 to 1.35), and all quality metrics also varied across hospitals. Across cost tertiles, there were no significant differences in the quality metrics examined, with the exception of PLOS. The PLOS findings were driven by high-risk The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery categories 4 and 5 cases (adjusted median length of stay 16.8 vs 14.9 days in high vs low cost tertile [ratio 1.13, 1.05 to 1.24]), and intensive care unit PLOS. CONCLUSIONS: Contemporary congenital heart surgery costs vary across hospitals but were not associated with most quality metrics examined, highlighting that performance in one area does not necessarily convey to others. Cost variability was associated with PLOS, particularly related to intensive care unit PLOS and high-risk cases. Care processes influencing PLOS may provide targets for value-based initiatives in this population.

Incremental effect of complications on mortality and hospital costs in adult ECMO patients.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality whose usage is expanding rapidly. It is a costly endeavor and best conducted in a multidisciplinary setting. There is a growing impetus to mitigate the mortality and costs associated with ECMO. We sought to examine the impact of complications on mortality and hospital costs in patients on ECMO. METHODS: Using the NIS database, we performed multivariable logistic regression to assess the influence of complications on the primary outcome, in-hospital mortality. Similarly, we performed multivariable survey linear regression analysis to evaluate the effect of the complications on hospital costs. RESULTS: Of the 12,637 patients supported using ECMO between 2004 and 2013, 9836 (78%) developed at least one complication. The three most common complications were acute kidney injury (32.8%), bloodstream infection (31.8%), and bleeding (27.8%). An ECMO hospitalization with no complications was associated with median costs of $53,470, a single complication with costs of $97,560, two complications with costs of $139,035, and three complication with costs of $162,284. A single complication was associated with a 165% increase in odds of mortality. Two or three complications resulted in 375% or 627% higher odds of mortality, respectively. Having one, two, or three complications was associated with 24%, 38%, or 38% increase in median costs respectively (Figure 1). Complications associated with the highest median costs were central line-associated bloodstream infection $217,751; liver failure $176,201; bloodstream infection $169,529. CONCLUSION: In-hospital mortality and costs increase with each incremental complication in patients on ECMO. Accurate prediction and mitigation of complications is likely to improve outcomes and cost.

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.

Vascular Complications Increase Hospital Charges and Mortality in Adult Patients on Extracorporeal Membrane Oxygenation in the United States.

Patients on extracorporeal membrane oxygenation (ECMO) who suffer vascular complications frequently accrue additional procedures and costs. We sought to evaluate the effect of ECMO-related vascular complications on hospital charges and in-hospital mortality. Adult discharges involving ECMO from 2004 to 2013 in the National Inpatient Sample were examined. There were 12,636 patients in the cohort. Vascular complications, focusing on arterial complications were identified using ICD-9-CM diagnosis and procedure codes. A multivariable survey linear regression model using median hospital charges was used to model the effect of vascular complications on charges. We used multivariable survey logistic regression to evaluate the effect of vascular complications on in-hospital mortality. Of the 12,636 patients examined, 6467 (51.2%) had ECMO-related vascular complications. Median charges in patients with vascular complications were $ 477,363 (interquartile range: 258,660-875,823) and were $ 282,298 (interquartile range: 130,030-578,027) without vascular complications. On multivariable analysis, patients with vascular complications had 24% higher median charges than patients without vascular complications (Ratio: 1.24; 95% confidence interval [CI]: 1.16-1.33; P < 0.0001) and 34% higher odds of experiencing in-hospital mortality than patients without vascular complications (adjusted odds ratio: 1.34; 95% CI:1.08-1.66; P = 0.009). Vascular complications occur in over half of ECMO patients and are associated with an increased risk of high hospital charges and in-hospital mortality. These findings support the need for identification and modification of risk factors for ECMO-related vascular complications. Furthermore, the standardization of protocols using evidence-based measures to mitigate vascular complications may improve overall ECMO outcomes.

Neurodegenerative disease is associated with increased incidence of epilepsy: a population based study of older adults.

OBJECTIVE: To determine the incidence of epilepsy among Medicare beneficiaries with a new diagnosis of Alzheimer dementia (AD) or Parkinson disease (PD). METHODS: Retrospective cohort study of Medicare beneficiaries with an incident diagnosis of AD or PD in the year 2009. The 5-year incidence of epilepsy was examined by sociodemographic characteristics, comorbidities and neurodegenerative disease status. Cox regression models examined the association of neurodegenerative disease with incident epilepsy, adjusting for demographic characteristics and medical comorbidities. RESULTS: We identified 178,593 individuals with incident AD and 104,157 individuals with incident PD among 34,054,293 Medicare beneficiaries with complete data in 2009. Epilepsy was diagnosed in 4.45% (7,956) of AD patients and 4.81% (5,010) of PD patients between 2009 and 2014, approximately twice as frequently as in the control sample. Minority race/ethnicity was associated with increased risk of incident epilepsy. Among individuals with AD and PD, stroke was associated with increased epilepsy risk. Traumatic brain injury (TBI) was associated with increased epilepsy risk for individuals with PD. Depression was also associated with incident epilepsy (AD adjusted hazard ratio (AHR): 1.23 (1.17-1.29), PD AHR: 1.45 (1.37-1.54)). In PD only, a history of hip fracture (AHR, 1.35 (1.17-1.57)) and diabetes (AHR, 1.11 (1.05-1.18) were also associated with increased risk of epilepsy. CONCLUSION: Incident epilepsy is more frequently diagnosed among neurodegenerative disease patients, particularly when preceded by a diagnosis of depression, TBI or stroke. Further studies into the differences in epilepsy risk between these two populations may help elucidate different mechanisms of epileptogenesis.

Impact of Hospitalization and Medication Switching on Post-discharge Adherence to Oral Anticoagulants in Patients With Atrial Fibrillation.

BACKGROUND: Adherence to chronic medications remains poor in practice. There is limited evidence on how hospitalization affects post-discharge adherence to oral anticoagulants (OACs) in individuals with atrial fibrillation. The aim of this study was to examine the impact of hospitalization and medication switching on post-discharge adherence to OACs in the population with atrial fibrillation. METHODS: A quasi-experimental pre-post observational study was conducted using United States commercial insurance health care claims from the 2009 to 2016 Optum database. Adults with atrial fibrillation taking OACs who had a random hospitalization occurring after the first observed OAC prescription fill and no other admission in the preceding and following 6 months were identified. OAC adherence was estimated by the proportion of days covered within 6 and 12 months before and after hospitalization. Difference-in-difference analysis was employed to compare the pre-hospitalization and post-hospitalization proportion of days covered, stratified by reasons for hospitalization (i.e., bleeding vs non-bleeding-related reasons) and adjusting for imbalanced baseline characteristics between groups. Change in adherence when the OAC was switched at discharge was also examined. RESULTS: The 22,429 individuals who met study criteria were predominantly male (52.4%), white (77.2%), and older age (median 74 years). A clinically significant hemorrhage was the reason for 1029 (4.5%) of qualifying hospitalizations. After covariate adjustment, there was a reduction in the proportion of days covered after discharge, regardless of admission diagnosis (p<0.0001). The 6-month difference-in-difference analyses revealed that adherence was incrementally reduced by 3.2% (p=0.0003) in the bleeding group compared with the nonbleeding group, whereas switching from warfarin to a direct oral anticoagulant after hospitalization was associated with a smaller reduction by 3.4% in adherence (p=0.0342) compared with other switchers, regardless of the reason for hospitalization. The 12-month difference-in-difference analyses revealed similar results. CONCLUSIONS: Hospitalization is temporally associated with a reduction in adherence to OACs, regardless of reason for hospitalization. More effective strategies are needed to improve OAC adherence, particularly during transition of care.

Unplanned Readmissions of Children With Epilepsy in the United States.

BACKGROUND: The burden and characteristics of unplanned readmission after epilepsy-related discharge in children in the United States is not known. METHODS: We undertook a retrospective cohort study of children aged one to 17 years discharged after a nonelective hospitalization for epilepsy, sampled from the Healthcare Cost and Utilization Project's 2013 and 2014 Nationwide Readmissions Database. Descriptive statistics and logistic regression models were used to examine the characteristics of initial hospitalization and risk factors for readmission. RESULTS: A total of 42,873 admissions for unique patients were identified, with 4470 (10.4%) leading to readmission within 30 days. The most common readmission diagnosis was epilepsy (24.9%). Neurodevelopmental diagnoses including cerebral palsy, intellectual disability, and developmental delay were associated with increased odds of readmission. Longer hospitalization, gastrostomy, and tracheostomy were also associated with readmission, but continuous electroencephalography use was not. Children insured by Medicare had a readmission rate of 34.4%, whereas there were no associations of readmission with other sociodemographic characteristics such as neighborhood, income, and sex. CONCLUSIONS: Seizures are among the most frequent reasons for hospitalization in children. Establishing a benchmark readmission rate for pediatric epilepsy of 10.4% may be useful to health systems designing quality improvement efforts. Clinical factors were more strongly associated with readmission than demographic characteristics. Interventions to reduce pediatric epilepsy readmissions may have the highest yield when targeting children with neurodevelopmental comorbidities.

Estimating Resource Utilization in Congenital Heart Surgery.

BACKGROUND: Optimal methods to assess resource utilization in congenital heart surgery remain unclear. We compared traditional cost-to-charge ratio methods with newer standardized cost methods that aim to more directly assess resources consumed. METHODS: Clinical data from The Society of Thoracic Surgeons Database were linked with resource use data from the Pediatric Health Information Systems Database (2010 to 2015). Standardized cost methods specific to the congenital heart surgery population were developed and compared with cost-to-charge ratio methods. Resource use in the overall population and variability across hospitals were described using hierarchical mixed effect models adjusting for case-mix. RESULTS: Overall, 43 hospitals (65,331 patients) were included. There were minimal population-level differences in the distribution of resource use as estimated by the two methods. At the hospital level, there was less apparent variability in resource use across centers with the standardized cost vs cost-to-charge ratio method, overall (coefficient of variation 20% vs 25%) and across complexity (The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT]) categories. When hospitals were categorized into tertiles by resource use, 33% changed classification depending on which resource use method was used (26% by one tertile and 7% by two tertiles). CONCLUSIONS: In this first evaluation of standardized cost methodology in the congenital heart population, we found minimal differences vs traditional methods at the population level. At the hospital level, the magnitude of variation in resource use was less with standardized cost methods, and approximately one third of centers changed resource use categories depending on the methodology used. Because of these differences, care should be taken in future studies and in benchmarking and reporting efforts in selecting optimal methodology.

Readmissions after hospital care for meningitis in the United States.

BACKGROUND: Our objectives were to (1) characterize patient and clinical characteristics of adults hospitalized with meningitis; (2) describe meningitis hospitalization outcomes, including 30- and 90-day readmissions; and (3) determine whether clinical, patient, or index hospitalization characteristics are associated with readmission and readmission outcomes. METHODS: This retrospective study of the 2014 National Readmissions Database extracted data on hospitalized adults with a principal diagnosis of meningitis and examined hospitalization outcomes using descriptive statistics. Logistic regression models were built to determine whether characteristics were associated with 30- or 90-day readmissions. RESULTS: For the 30-day readmission analyses, 18,883 adults qualified. Meningitis hospitalizations commonly involved adults 25 to 54 years of age who were insured by private carriers. The readmission rates were 7.0% at 30 days and 11.4% at 90 days. Readmission was associated with greater comorbidity burden (2 conditions: adjusted odds ratio [AOR] = 1.60, range 1.24-2.08; 3 conditions: AOR = 1.92, range 1.43-2.58; 4+ conditions: AOR = 2.68, range 2.04-3.51 vs 0 or 1 condition), public insurance (Medicare: AOR = 1.85, range 1.30-2.62; Medicaid: AOR = 1.48, range 1.16-1.90 vs private insurance), and medical error (AOR = 1.43, range 1.07-1.91). Readmissions were most often for meningitis, septicemia, or medical complications. CONCLUSIONS: Readmission after hospitalization for meningitis is associated with both fixed and modifiable factors. More research is needed to determine which post-meningitis readmissions are preventable.

Distressed communities are associated with worse outcomes after coronary artery bypass surgery.

OBJECTIVES: Although low socioeconomic status has been associated with increased risk of complications after cardiac surgery, analyses have typically focused on insurance status, race, or median income. We sought to determine if the Distressed Communities Index, a composite socioeconomic metric, could predict operative mortality after coronary artery bypass grafting. METHODS: All patients who underwent isolated coronary artery bypass grafting (2011-2018) in the National Society of Thoracic Surgeons adult cardiac surgery database were analyzed. Clinical data were paired with the Distressed Communities Index, which accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies by ZIP code. Developed by the Economic Innovation Group, Distressed Communities Index scores range from 0 (no distress) to 100 (severe distress). A distressed community was defined as one having a Distressed Communities Index of 75 or greater for univariate analyses. RESULTS: Of the 575,900 patients undergoing coronary artery bypass grafting with a Distressed Communities Index score, the median age was 65 years. The operative mortality rate was 2.0%, and the composite morbidity or mortality rate was 11.5%. Distressed communities were associated with increased Society of Thoracic Surgeons predicted risk of mortality (1.97% vs 1.85%, P < .0001) and risk of composite morbidity or mortality (12.8% vs 11.7%, P < .0001). After adjusting for Society of Thoracic Surgeons risk model, the Distressed Communities Index remained significantly associated with mortality (odds ratio, 1.12; P < .0001) and composite morbidity and mortality (odds ratio, 1.03; P = .002). CONCLUSIONS: Patients from distressed communities are at increased risk for adverse events and death after coronary artery bypass grafting. The Distressed Communities Index is a useful, holistic measure of socioeconomic status that may help identify high-risk patients for quality improvement and should be considered when building risk models or comparing hospitals.

Understanding nationwide readmissions after thyroid surgery.

BACKGROUND: The 30-day readmission rate is increasingly utilized as a metric of quality that impacts reimbursement. To date, there are no nationally representative data on readmission rates after thyroid surgery. We aimed to determine national readmission rates after inpatient thyroidectomy operations and whether select clinical factors were associated with increased odds of postthyroidectomy readmission. METHODS: Using the 2014 Nationwide Readmissions Database, we identified patients undergoing inpatient thyroid surgery as defined by the International Classification of Diseases, Ninth Revision, procedure codes for thyroid lobectomy, partial thyroidectomy, complete thyroidectomy, and substernal thyroidectomy. Descriptive statistics were used to report readmission rates, most common diagnosis and causes of readmission, and timing of presentation after discharge. Multivariable logistic regression models controlling for potential confounders were used to determine whether select factors were associated with 30-day readmission. RESULTS: A total of 22,654 patients underwent inpatient thyroid surgery during the study period, 990 of whom (4.4%) were readmitted within 30 days. Among these, the most common diagnoses during readmission were disorders of mineral metabolism and hypocalcemia, accounting for 36.0% and 26.6% of readmissions, respectively. This held true regardless of the apparent indication for thyroid surgery (goiter, cancer, or thyroid function disorder) or timing of readmission after discharge. Calcium-related abnormalities were the top diagnoses at readmissions (22.1%). Most readmissions (54.6%) occurred within 7 days of discharge, with 24.6% within the first 2 days Factors associated with an increased odds of readmission included having Medicare (adjusted odds ratio [AOR] 1.47 and 95% confidence interval [CI] 1.03-2.11) or Medicaid insurance (AOR 1.44 [CI 1.04-1.99]), being discharged to inpatient post acute care (AOR 2.31 [CI 1.48-3.62]) or to home health care (AOR 1.78 [CI 1.21-2.63]), having an Elixhauser comorbidity score ≥ 4 (AOR 2.04 [CI 1.27-3.26]), and a duration of stay ≥2 days after the thyroid surgery (AOR 2.7 [CI 1.9-3.82]). The only complication during index admission associated with increased odds of readmission was hypocalcemia (AOR 1.5 [CI 1.1-2.06]. Indications for thyroid surgery were not associated with increased odds of readmission. CONCLUSION: Readmissions after thyroid surgery are relatively low and occur early after surgery. The most common diagnoses identified on readmission were calcium and mineral metabolism disorders, which also were the most common cause of readmission. Socioeconomic factors, comorbidities, and complications during the index admissions were found to be associated with nonelective, postthyroidectomy readmissions. Recognition of these risk factors may guide the development of interventions and protocols to decrease readmissions.

Sex disparities in health and health care utilization after Parkinson diagnosis: Rethinking PD associated disability.

OBJECTIVE: To examine sex differences and trends in comorbid disease and health care utilization in individuals with newly diagnosed Parkinson disease (PD). DESIGN: Retrospective cohort study. PARTICIPANTS: Over 133,000 Medicare beneficiaries with a new PD diagnosis in 2002 followed through 2008. METHODS: We compared the prevalence and cumulative incidence of common medical conditions, trends in survival and health care utilization between men and women with PD. RESULTS: Female PD patients had higher adjusted incidence rate ratio (IRR) of depression (IRR: 1.28, 1.25-1.31), hip fracture (IRR: 1.51, 1.45-1.56), osteoporosis (3.01, 2.92-3.1), and rheumatoid/osteoarthritis (IRR: 1.47, 1.43-1.51) than men. In spite of greater survival, women with PD used home health and skilled nursing facility care more often, and had less outpatient physician contact than men throughout the study period. CONCLUSIONS: Women experience a unique health trajectory after PD diagnosis as suggested by differing comorbid disease burden and health care utilization compared to men. Future studies of sex differences in care needs, care quality, comorbidity related disability, PD progression, and non-clinical factors associated with disability are needed to inform research agendas and clinical guidelines that may improve quality survival for women with PD.

Utilization of rehabilitation therapy services in Parkinson disease in the United States.

OBJECTIVE: To examine rehabilitation therapy utilization for Parkinson disease (PD). METHODS: We identified 174,643 Medicare beneficiaries with a diagnosis of PD in 2007 and followed them through 2009. The main outcome measures were annual receipt of physical therapy (PT), occupational therapy (OT), or speech therapy (ST). RESULTS: Outpatient rehabilitation fee-for-service use was low. In 2007, only 14.2% of individuals with PD had claims for PT or OT, and 14.6% for ST. Asian Americans were the highest users of PT/OT (18.4%) and ST (18.4%), followed by Caucasians (PT/OT 14.4%, ST 14.8%). African Americans had the lowest utilization (PT/OT 7.8%, ST 8.2%). Using logistic regression models that accounted for repeated measures, we found that African American patients (adjusted odds ratio [AOR] 0.63 for PT/OT, AOR 0.63 for ST) and Hispanic patients (AOR 0.97 for PT/OT, AOR 0.91 for ST) were less likely to have received therapies compared to Caucasian patients. Patients with PD with at least one neurologist visit per year were 43% more likely to have a claim for PT evaluation as compared to patients without neurologist care (AOR 1.43, 1.30-1.48), and this relationship was similar for OT evaluation, PT/OT treatment, and ST. Geographically, Western states had the greatest use of rehabilitation therapies, but provider supply did not correlate with utilization. CONCLUSIONS: This claims-based analysis suggests that rehabilitation therapy utilization among older patients with PD in the United States is lower than reported for countries with comparable health care infrastructure. Neurologist care is associated with rehabilitation therapy use; provider supply is not.

Hospital care for mental health and substance abuse in children with epilepsy.

BACKGROUND: Reducing the burden of pediatric mental illness requires greater knowledge of mental health and substance abuse (MHSA) outcomes in children who are at an increased risk of primary psychiatric illness. National data on hospital care for psychiatric illness in children with epilepsy are limited. METHODS: We used the Kids' Inpatient Database (KID), the Healthcare Cost and Utilization Project (HCUP), and the Agency for Healthcare Research and Quality from 2003 to 2009 to examine MHSA hospitalization patterns in children with comorbid epilepsy. Nonparametric and regression analyses determined the association of comorbid epilepsy with specific MHSA diagnoses and examined the impact of epilepsy on length of stay (LOS) for such MHSA diagnoses while controlling for demographic, payer, and hospital characteristics. RESULTS: We observed 353,319 weighted MHSA hospitalizations of children ages 6-20; 3280 of these involved a child with epilepsy. Depression was the most common MHSA diagnosis in the general population (39.5%) whereas bipolar disorder was the most common MHSA diagnosis among children with epilepsy (36.2%). Multivariate logistic regression models revealed that children with comorbid epilepsy had greater adjusted odds of bipolar disorder (AOR: 1.17, 1.04-1.30), psychosis (AOR: 1.78, 1.51-2.09), sleep disorder (AOR: 5.90, 1.90-18.34), and suicide attempt/ideation (AOR: 3.20, 1.46-6.99) compared to the general MHSA inpatient population. Epilepsy was associated with a greater LOS and a higher adjusted incidence rate ratio (IRR) for prolonged LOS (IRR: 1.12, 1.09-1.17), particularly for suicide attempt/ideation (IRR: 3.74, 1.68-8.34). CONCLUSIONS: Children with epilepsy have distinct patterns of hospital care for mental illness and substance abuse and experience prolonged hospitalization for MHSA conditions. Strategies to reduce psychiatric hospitalizations in this population may require disease-specific approaches and should measure disease-relevant outcomes. Hospitals caring for large numbers of children with neurological disease (such as academic centers) may have inaccurate measurements of mental health-care quality unless the impact of key comorbid conditions such as epilepsy is considered.

Demographics, disparities, and outcomes in substernal goiters in the United States.

BACKGROUND: Disparities distinguishing patients with substernal goiters from nonsubsternal goiters have not been thoroughly described. METHODS: The National Inpatient Sample database was used to compare patients who underwent substernal thyroidectomy years 2000 to 2010 with those who underwent thyroidectomy for nonsubsternal goiter. RESULTS: A total of 110,889 patients underwent thyroidectomy for goiter (5,525 substernal and 105,364 nonsubsternal). Substernal thyroidectomy patients were older, more likely to be Black or Hispanic and to have Medicare insurance. They had a higher comorbidity index, were more likely to be admitted emergently and to have postoperative complications such as hemorrhage/hematoma, pneumothorax, pulmonary embolism, and hypocalcemia/hypoparathyroidism. Furthermore, substernal thyroidectomy patients had 73% increased odds of death during admission than nonsubsternal thyroidectomy patients. CONCLUSIONS: Substernal goiters present a distinct type of goiter with identifiable patient-level characteristics and an increased risk of postoperative complications and death. Earlier identification and treatment of goiters may allow earlier interventions at a stage when risks are reduced.

Nursing home and end-of-life care in Parkinson disease.

OBJECTIVE: To examine long-term care facility (LTCF or nursing home) use and end-of-life care for individuals with Parkinson disease (PD). METHODS: In this nationwide retrospective cohort study, we compared LTCF and hospice utilization among Medicare beneficiaries diagnosed with PD by demographic, clinical, and physician characteristics. We also examined the impact of outpatient neurologist care for institutionalized patients with PD on end-of-life care. RESULTS: We identified 469,055 individuals with PD who received Medicare benefits in 2002. Nearly 25% (more than 100,000 in total) resided in an LTCF. Women with PD had greater odds of nursing facility residence (adjusted odds ratio [AOR] 1.34, 95% confidence interval [CI] 1.30-1.38) compared with men. Black individuals with PD were 34% more likely than white individuals to reside in an LTCF (AOR 1.34, 95% CI 1.30-1.38), contrary to the race patterns typically observed for LTCF use. Hip fracture (AOR 2.10, 95% CI 2.04-2.15) and dementia (AOR 4.06, 95% CI 4.00-4.12) were the strongest clinical predictors of LTCF placement. Only 33% (n = 38,334) of nursing home residents with PD had outpatient neurologist care. Eighty-four percent (n = 80,877) of LTCF residents with PD died by December 31, 2005. Hospice utilization varied little by race and sex. LTCF residents who had outpatient neurologist care were twice as likely to utilize hospice services before death (AOR 2.35, 95% CI 2.24-2.47). CONCLUSIONS AND RELEVANCE: A large proportion of the Medicare PD population resides in an LTCF. There is substantial unmet need for palliative care in the PD population. Increased efforts to provide specialist care to dependent individuals with PD may improve end-of-life care.