An Observation of Racial and Gender Disparities in Congestive Heart Failure Admissions Using the National Inpatient Sample.

Background Congestive heart failure (CHF) is a frequent cause of inpatient admissions in the United States. The purpose of this study was to analyze the racial and gender disparities that occur in CHF admissions and determine the impact of these disparities on medical expenditure. Methods We analyzed the National Inpatient Sample (NIS) database from 2009 to 2014 for patients with a primary discharge diagnosis of CHF, and further stratified the cohort on the basis of race and sex. Multivariate analysis was performed to identify the association between CHF and total charges along with other variables such as mortality, length of stay (LOS), and number of procedures. Results There were a total of 5,491,050 admissions with a primary diagnosis of CHF from 977,850 in 2009 to 901,425 in 2014. Females accounted for 49.7%. Total charges for CHF admission were highest in Asians at an average cost of $59,668. African Americans had the lowest mortality rate at 1.75%, however, they also had an average age of admission of 63.47 years, compared to Caucasian at 76.76 (p<0.05). Total charges for males were $42,920 and $36,744 for females (p <0.05). Males also had more procedures at 1.16 vs 0.98 for females (p <0.05). Elixhauser mortality score was higher in males than females at 5.95 vs 5.42 (p <0.05). Conclusion Healthcare disparities exist in CHF admissions in both contexts of race and gender. Further studies are required to pinpoint the source of these differences not only to address mortality but also expenditure costs.

Short-term outcomes associated with inpatient ventricular tachycardia catheter ablation.

BACKGROUND: Utilization of catheter ablation of ventricular tachycardia (VT) has steadily increased in recent years. Exploring short-term outcomes is vital in health care planning and resource allocation. METHODS: The Nationwide Readmissions Database from 2010 to 2014 was queried using the ICD-9 codes for VT (427.1) and catheter ablation (37.34) to identify study population. Incidence, causes of 30-day readmission, in-hospital complications as well as predictors of 30-day readmissions, complications, and cost of care were analyzed. RESULTS: Among 11 725 patients who survived to discharge after index admission for VT ablation, 1911 (16.3%) were readmitted within 30 days. Paroxysmal VT was the most common cause of 30-day readmission (39.51%). Dyslipidemia, chronic kidney disease (CKD), previous CABG, congestive heart failure (CHF), chronic pulmonary disease, and anemia predicted increased risk of 30-day readmissions. The overall in-hospital complication rate was 8.2% with vascular and cardiac complications being the most common. Co-existing CKD and CHF and the need for mechanical circulatory support (MCS) predicted higher complication rates. Similarly increasing age, CKD, CHF, anemia, in-hospital use of MCS or left heart catheterization, teaching hospital, and disposition to nursing facilities predicted higher cost. CONCLUSION: Approximately one in six patients was readmitted after VT ablation, with paroxysmal VT being the most common cause of the readmission. A complication rate of 8.2% was noted. We also identified a predictive model for increased risk of readmission, complication, and factors influencing the cost of care that can be utilized to improve the outcomes related to VT ablation.

Outcomes and Resource Utilization Associated With Readmissions After Atrial Fibrillation Hospitalizations.

Background Atrial fibrillation is the most common arrhythmia worldwide. Data regarding 30-day readmission rates after discharge for atrial fibrillation remain poorly reported. Methods and Results The Nationwide Readmission Database (2010-2014) was queried using the International Classification of Diseases, Ninth Revision (ICD-9) codes to identify study population. Incidence, etiologies of 30-day readmission and predictors of 30-day readmissions, and cost of care were analyzed. Among 1 723 378 patients who survived to discharge, 249 343 (14.4%) patients were readmitted within 30 days. Compared with the readmitted group, the nonreadmitted group had higher utilization of electrical cardioversion and catheter ablation. Atrial fibrillation was the most common cause of readmission (24.1%). Median time to 30-day readmission was 13 days. Advancing age, female sex, and longer stay during index hospitalization predicted higher 30-day readmissions, whereas private insurance, electrical cardioversion, catheter ablation, higher income, and elective admissions correlated with lower 30-day readmission. Comorbidities such as heart failure, neurological disorder, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, chronic liver failure, coagulopathy, anemia, peripheral vascular disease, and electrolyte disturbance, correlated with increased 30-day readmissions and cost burden. Trend analysis showed a progressive decline in 30-day readmission rates from 14.7% in 2010 to 14.3% in 2014 (P trend, <0.001). Conclusions Approximately 1 in 7 patients were readmitted within 30 days of discharge, with symptomatic atrial fibrillation being the most common cause. We identified a predictive model for increased risk of readmissions and treatment expense. Electrical cardioversion during index admission was associated with a significant reduction in 30-day readmissions and service charges. The 30-day readmissions correlated with a substantial rise in the cost of care.

Frequency of 30-day readmission and its causes after percutaneous coronary intervention in acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: Survival after percutaneous coronary intervention (PCI) in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) has increased over the years. Short-term readmission rates in this high-risk population remain unknown. METHODS: We queried the United States (U.S.) Nationwide Readmission Database (NRD) from January 2010 to November 2014 using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9 CM) codes to identify all patients ≥18 years readmitted within 30 days after surviving an index hospitalization for PCI in AMI-CS. Incidence, etiologies, and predictors of 30-day readmission were analyzed. RESULTS: Among 46,435 patients who survived to discharge after PCI in AMI-CS, 9,020 (19.4%) were readmitted within 30 days. Median time to 30-day readmission was 11 days. Cardiac conditions were the most common causes of readmission (57.8%). Heart failure was the leading readmission diagnosis (24.8%). Private insurance including HMO and self-pay were predictive of lower 30-day readmission. Among other covariates, female sex, comorbidities such as heart failure, atrial fibrillation, in-hospital complications such as major bleeding, sepsis, respiratory complications, AKI requiring dialysis, utilization of mechanical circulatory support (IABP and ECMO) were independently predictive of 30-day readmission. Trend analysis showed decline in 30-day readmission rates from 21.9% in 2010 to 17.9% in 2014 (ptrend < 0.001). CONCLUSION: In this large real-world database, one in five patients receiving PCI in AMI-CS was readmitted within 30 days after discharge. Cardiac conditions were the most common causes of readmission. Insurance type had significant influence on 30-day readmission.

Heart failure: Same-hospital vs. different-hospital readmission outcomes.

BACKGROUND: Heart Failure (HF) is a major driver of the readmissions/penalties in the US. Although extensive literature on rehospitalization attributed to HF, studies to compare outcomes for same-hospital vs. different-hospital readmissions are sparse. METHODS: Nationwide Readmission Database from 2010 to 14 utilized for HF-related hospitalization using appropriate ICD-9-CM diagnostic codes. 30-day readmissions were classified into two groups: same-hospital and different-hospital. A comparative analysis was conducted focusing on: in-hospital mortality, length of stay (LOS) and hospitalization cost. Hierarchical two-level modeling and propensity score matching utilized to adjust confounders. RESULTS: 715,993 HF readmissions were identified, of which 21.3% were readmitted to different-hospital. Elderly, females, patients with higher co-morbidities and higher median household income were less likely to be readmitted to different-hospital. Index hospitalizations in a teaching hospital and/or larger hospital were associated with reduced different-hospital readmissions. Readmissions to the different hospital were associated with higher in-hospital mortality (7.7% vs. 6.6%, p < 0.001), higher resource utilization (LOS:7.5 days vs. 6.1 days, p < 0.001 and Cost: $22,602 vs. $13,740, p < 0.001) after adjusting for propensity score match. Similar results were observed with propensity score matching of multiple high-risk subgroups. CONCLUSION: Resources should be directed towards minimizing different-hospital HF readmissions to improve patient outcomes by identifying the vulnerable subgroup and further tailoring in-hospital and post-discharge care.

Etiologies, predictors, and economic impact of readmission within 1 month among patients with takotsubo cardiomyopathy.

BACKGROUND: Limited data exist on readmission among patients with takotsubo cardiomyopathy (TC), a commonly reversible cause of heart failure. HYPOTHESIS: We sought to identify etiologies and predictors for readmission among TC patients. METHODS: We queried the National Readmissions Database for 2013-2014 to identify patients with primary admission for TC using ICD-9-CM code 429.83. Patients readmitted to hospital within 1 month after discharge were further evaluated to identify etiologies, predictors, and resultant economic burden of readmission. Additionally, we analyzed readmission for TC at 6 months. RESULTS: We studied 5997 patients admitted with TC, of whom 1.2% experienced in-hospital mortality. Median age was 67 years, with 91.5% being female. Among survivors, 10.3% were readmitted within 1 month; 25% of the initial 1-month readmissions occurred within 4 days, 50% within 10 days, and 75% within 20 days from discharge. The most common etiologies for readmission were cardiac (26%), respiratory (16%), and gastrointestinal (11%) causes. Heart failure was the most common cardiac etiology. Significant predictors of increased 1-month readmission included systemic thromboembolic events, length of stay ≥3 days, and underlying psychoses. Obesity and private insurance predicted lower 1-month readmission. The annual national cost impact for index admission and 1-month readmissions was ≈$112 million. Recurrent TC was seen among 1.9% of patients readmitted within 6 months. CONCLUSIONS: Though the overall rate of 1-month readmission following TC is low, associated economic burden from readmission is still significant. Patients are readmitted mostly for noncardiac causes. Readmission for another episode of TC within 6 months was uncommon.

Etiologies, Predictors, and Economic Impact of 30-Day Readmissions Among Patients With Peripartum Cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a pregnancy-associated cause of heart failure. Given the significant impact of heart failure on healthcare, we sought to identify etiologies and predictive factors for readmission in PPCM. We queried the 2013 to 2014 National Readmissions Database to identify patients admitted with a diagnosis of PPCM. Patients who were readmitted within 30 days were evaluated to identify etiologies and predictors of readmission. We identified 6,977 index admissions with PPCM. Of the 6,880 (98.6%) patients who survived the index hospitalization, 30-day readmission rate was 13%. Seventy-six percent of readmitted patients were admitted once, and the other 24% were readmitted at least twice within 30 days of discharge. Length of stay was ≥8 days (adjusted odds ratio [aOR] 2.80, 95% confidence interval [CI] 2.08 to 3.77), multiparity (aOR 2.07, 95% CI 1.09 to 3.92), coronary artery disease (aOR 2.28, 95% CI 1.42 to 3.67), and long-term anticoagulation use (aOR 2.51, 95% CI 1.73 to 3.64) were independently associated with increased risk of 30-day readmission. Among the readmissions, 48% were due to cardiac causes, where PPCM and related complications (24%) were the most common cardiac cause followed by heart failure (16%). The annual cost of stay for index admissions was $64.2 million (average cost for index admission was $16,892). The annual charges attributed to readmission within 30 days were ≈$9 million. Cardiac etiologies were the most common cause for 30-day readmissions in PPCM patients, with a readmission rate of 13%. Long-term anticoagulation use, multiparity, coronary disease and length of stay predicted higher 30-day readmission.

Etiologies, Trends, and Predictors of 30-Day Readmission in Patients With Heart Failure.

Heart failure (HF) is the most common discharge diagnosis across the United States, and these patients are particularly vulnerable to readmissions, increasing attention to potential ways to address the problem. The study cohort was derived from the Healthcare Cost and Utilization Project's National Readmission Data 2013, sponsored by the Agency for Healthcare Research and Quality. HF was identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. Readmission was defined as a subsequent hospital admission within 30 days after discharge day of index admission. Readmission causes were identified using International Classification of Diseases, Ninth Revision, codes in primary diagnosis filed. The primary outcome was 30-day readmission. Hierarchical 2-level logistic models were used to evaluate study outcomes. From a total 301,892 principal admissions (73.4% age ≥65 years and 50.6% men), 55,857 (18.5%) patients were readmitted with a total of 64,264 readmissions during the study year. Among the etiologies of readmission, cardiac causes (49.8%) were most common (HF being most common followed by coronary artery disease and arrhythmias), whereas pulmonary causes were responsible for 13.1% and renal causes for 8.9% of the readmissions. Significant predictors of increased 30-day readmission included diabetes (odds ratio, 95% confidence interval, p value: 1.06, 1.03 to 1.08, p <0.001), chronic lung disease (1.13, 1.11 to 1.16, p <0.001), renal failure/electrolyte imbalance (1.12, 1.10 to 1.15, p <0.001), discharge to facilities (1.07, 1.04 to 1.09, p <0.001), lengthier hospital stay, and transfusion during index admission. In conclusion, readmission after a hospitalization for HF is common. Although it may be necessary to readmit some patients, the striking rate of readmission demands efforts to further clarify the determinants of readmission and develop strategies in terms of quality of care and care transitions to prevent this adverse outcome.

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.

Comparison of Inhospital Outcomes and Hospitalization Costs of Peripheral Angioplasty and Endovascular Stenting.

The comparative data for angioplasty and stenting for treatment of peripheral arterial disease are largely limited to technical factors such as patency rates with sparse data on clinical outcomes like mortality, postprocedural complications, and amputation. The study cohort was derived from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2006 to 2011. Peripheral endovascular interventions were identified using appropriate International Classification of Diseases, Ninth Revision (ICD-9) Diagnostic and procedural codes. Two-level hierarchical multivariate mixed models were created. The primary outcome includes inhospital mortality, and secondary outcome was a composite of inhospital mortality and postprocedural complications. Amputation was a separate outcome. Hospitalization costs were also assessed. Endovascular stenting (odds ratio, 95% confidence interval, p value) was independently predictive of lower composite end point of inhospital mortality and postprocedural complications compared with angioplasty alone (0.96, 0.91 to 0.99, 0.025) and lower amputation rates (0.56, 0.53 to 0.60, <0.001) with no significant difference in terms of inhospital mortality alone. Multivariate analysis also revealed stenting to be predictive of higher hospitalization costs ($1,516, 95% confidence interval 1,082 to 1,950, p <0.001) compared with angioplasty. In conclusion, endovascular stenting is associated with a lower rate of postprocedural complications, lower amputation rates, and only minimal increase in hospitalization costs compared with angioplasty alone.

Impact of Hospital Volume on Outcomes of Lower Extremity Endovascular Interventions (Insights from the Nationwide Inpatient Sample [2006 to 2011]).

Our primary objective was to study postprocedural outcomes and hospitalization costs after peripheral endovascular interventions and the multivariate predictors affecting the outcomes with emphasis on hospital volume. The study cohort was derived from Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2006 to 2011). Peripheral endovascular interventions were identified using appropriate International Classification of Diseases, Ninth Revision diagnostic and procedural codes. Annual institutional volumes were calculated using unique identification numbers and then divided into quartiles. Two-level hierarchical multivariate mixed models were created. The primary outcome was inhospital mortality; secondary outcome was a composite of inhospital mortality and postprocedural complications. Amputation rates and hospitalization costs were also assessed. Multivariate analysis (odds ratio, 95% confidence interval, p value) revealed age (1.46, 1.37 to 1.55, p <0.001), female gender (1.28, 1.12 to 1.46, p <0.001), baseline co-morbidity status as depicted by a greater Charlson co-morbidity index score (≥2: 4.32, 3.45 to 5.40, p <0.001), emergent or urgent admissions(2.48, 2.14 to 2.88, p <0.001), and weekend admissions (1.53, 1.26 to 1.86, p <0.001) to be significant predictors of primary outcome. An increasing hospital volume quartile was independently predictive of improved primary (0.65, 0.52 to 0.82, p <0.001 for the fourth quartile) and secondary (0.85, 0.73 to 0.97, 0.02 for the fourth quartile) outcomes and lower amputation rates (0.52, 0.45 to 0.61, p <0.001). A significant reduction hospitalization costs ($-3,889, -5,318 to -2,459, p <0.001) was also seen in high volume centers. In conclusion, a greater hospital procedural volume is associated with superior outcomes after peripheral endovascular interventions in terms of inhospital mortality, complications, and hospitalization costs.