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

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

Pregnancy costs with commercial insurance.

BACKGROUND: Costs for obstetrical care may be increasing for both patients and insurers. OBJECTIVE: To examine predictors of and trends in the cost of medical care during pregnancy. STUDY DESIGN: We performed a study of pregnancies from 2009 to 2019 covered by commercial insurance resulting in term, singleton delivery hospitalizations and included in the MarketScan database. The analysis categorized pregnancies based on whether delivery occurred via cesarean versus vaginal delivery and whether pre-gestational diabetes or chronic hypertension was present. We estimated inflation-adjusted total medical costs from 273 days before through 42 days after delivery hospitalization discharge. The analysis evaluated costs for inpatient services, outpatient services, and outpatient drugs separately and trended these costs over the study period. The analysis dichotomized total medical costs into insurer liability versus out-of-pocket patient costs. The study used quantile regression models fit separately to evaluate costs for vaginal and cesarean delivery including demographic and medical characteristics. RESULTS: The analysis included 1,952,432 pregnancies covered by commercial insurance. From 2009 to 2019, median total medical costs increased from $14,091 (IQR $11,122-$18,417) to $19,645 (IQR $14,676-$27,959) with median inpatient costs increasing 36% and median outpatient costs increasing 43%. Out-of-pocket costs rose 65% for inpatient services and 120% for outpatient services. Median total pregnancy costs were higher for women with chronic hypertension (median $22,268, IQR $16,809-$30,901, p < .01), pregestational diabetes (median $20,786, IQR $15,702-$28,714, p < .01), and cesarean delivery (median $20,098, IQR $15,748-$26,889 versus median $14,904, IQR $11,728-$19,785 for vaginal delivery, p < .01). In adjusted analyses, chronic hypertension, diabetes, and cesarean delivery were associated with increased median total costs. CONCLUSION: Total and out-of-pocket medical costs for maternity care are increasing among commercially insured patients. Chronic hypertension, pregestational diabetes, and cesarean delivery are important predictors of costs.

Postpartum cardiac readmissions among women without a cardiac diagnosis at delivery.

OBJECTIVE: To determine risk for cardiac readmissions among women without cardiac diagnoses present at delivery up to 9 months after delivery hospitalization discharge. METHODS: Delivery hospitalizations without cardiac diagnoses were identified from the 2010-2014 Nationwide Readmissions Database and linked with subsequent cardiac hospitalizations over the following 9 months. The temporality of new-onset cardiac hospitalizations was calculated for each 30-day interval from delivery discharge up to 9 months postpartum. Multivariable log-linear regression models were fit to identify risk factors for cardiac readmissions adjusting for patient, medical, and obstetrical factors with adjusted risk ratios as measures of effect (aRR). RESULTS: Among 4.4 million delivery hospitalizations without a cardiac diagnosis, readmission for a cardiac condition within 9 months occurred in 26.8 per 10,000 women. Almost half of readmissions (45.9%) occurred within the first 30 days after delivery discharge with subsequent hospitalizations broadly distributed over the remaining 8 months. Factors such as hypertensive diseases of pregnancy (aRR 2.19, 95% CI 2.09, 2.30), severe maternal morbidity at delivery (aRR 2.06, 95% CI 1.79, 2.37), chronic hypertension (aRR 2.52, 95% CI 2.31, 2.74), lupus (aRR 4.62, 95% CI 3.82, 5.60), and venous thromboembolism during delivery (aRR 3.72, 95% CI 2.75, 5.02) were all associated with increased risk for 9-month postpartum cardiac admissions as were Medicaid (aRR 1.57, 95% CI 1.51, 1.64) and Medicare insurance (aRR 3.06, 95% CI 2.70, 3.46) compared to commercial insurance and maternal ages 35-39 and 40-54 years (aRR 1.24, 95% CI 1.17, 1.32, aRR 1.74, 95% CI 1.60, 1.90, respectively) compared to maternal age 25-29 years. CONCLUSIONS: Among women without a cardiac diagnosis at delivery, multiple medical factors and obstetrical complications are associated with development of new cardiac disease requiring readmission in the postpartum period. Given that pregnancy complications and comorbidities may be associated with intermediate-term health outcomes, these findings support the importance of continued health care access after six weeks postpartum.

Longitudinal Risk Adjustment for Maternal End-Organ Injury and Death.

OBJECTIVE: To determine whether adjusting for healthcare utilization and comorbidity diagnosed in the year before delivery improves the prediction of adverse maternal outcomes. METHODS: The Truven Health MarketScan database was used to determine whether healthcare utilization and comorbidity diagnosed in the year before pregnancy improved prediction of acute organ injury or death during the delivery hospitalization through 30 days postpartum in this retrospective cohort study. In an initial model, we analyzed the risk for adverse outcomes controlling for underlying comorbidity, obesity, and demographic risk factors present during pregnancy. Subsequent models included diagnoses from the year before pregnancy as well as whether patients had emergency department encounters, inpatient hospitalizations, or received medications from a pharmacy. We compared risk estimates and whether prediction of acute organ injury or death improved with data from the year before pregnancy. Unadjusted and adjusted log-linear regression models were performed to demonstrate the association between exposures and outcomes with unadjusted (RR) and adjusted risk ratios (aRR) with 95% CIs as measures of effects. Logistic regression was performed to calculate the c-statistic of the adjusted models. Separate analyses were performed for patients with Medicaid and commercial insurance. An analysis of Medicaid patients by maternal race and ethnicity was performed to determine if diagnoses and utilization before pregnancy accounted for maternal disparities. RESULTS: A total of 740,002 patients were analyzed in this study. In unadjusted analyses of patients with commercial insurance, ≥2 compared to 0 emergency department encounters (RR = 1.82, 95% CI = 1.61, 2.07), ≥2 compared to 0 inpatient hospitalizations (RR = 4.43, 95% CI = 3.20, 6.13), and receipt of medications from ≥5 prescription groups compared to no prescriptions (RR = 1.97, 95% CI = 1.74, 2.24) were all associated with increased risk for acute organ injury or death. Higher underlying comorbidity and obesity were also associated with increased risk. These risks were attenuated in adjusted analyses but retained significance. Risk estimates were similar for patients with Medicaid insurance with the exception of receipt of medications from ≥5 prescription groups which was non-significant in adjusted analyses (aRR = 1.12, 95% CI = 0.90, 1.40). C-statistics from logistic regression models were similar for models with and without pre-pregnancy data. When race was added to the adjusted models, risk among black women in the adjusted models did not differ significantly from the unadjusted estimate. CONCLUSION: ED encounters and inpatient admissions the year before pregnancy were associated with increased risk of adverse maternal outcomes. However, adding these risk factors to adjusted models did not meaningfully improve the amount of variance accounted for. Further research is indicated to determine to what degree longitudinal care quality is associated with maternal risk.

Risk of Postpartum Flare Hospitalizations in Patients with Inflammatory Bowel Disease Persists After Six Months.

BACKGROUND: Although patients with IBD are at higher risk for flares during the postpartum period, little is known about the risk factors, timeline, and healthcare-associated costs of a readmission flare. AIMS: To ascertain the timeline in which patients are hospitalized for postpartum inflammatory bowel disease (IBD) flares, and the associated risk factors. METHODS: This is a nationwide retrospective cohort study of 7054 patients with IBD who delivered between 2010-2014 obtained from the National Readmissions Database. The presence of IBD was defined using previously validated International Classification of Diseases codes, and univariable and multivariable regression models were performed to assess risk factors associated with a postpartum flare hospitalization over the nine-month observation period. RESULTS: A total of 353 (5.0%) patients were hospitalized for a postpartum IBD flare, with approximately one-third (30.0%) readmitted after 6 months. On multivariable analysis, having Crohn's disease (aRR 1.47, 95%CI 1.16-1.88), Medicare insurance (aRR 3.30, 95%CI 2.16-5.02), and ≥ 2 comorbidities (aRR 1.34, 95%CI 1.03-1.74) were independently associated with a higher risk of an IBD flare hospitalization. Compared to patients aged 25-29, those 20-24 were at higher risk for an IBD flare readmission (aRR 1.58, 95%CI 1.17-2.13), whereas patients aged 35-39 years were at lower risk (aRR 0.63, 95%CI 0.43-0.92). CONCLUSIONS: Among patients with IBD, Crohn's disease, Medicare insurance, multiple comorbidities, and younger age were independent risk factors for a postpartum IBD flare hospitalization. As approximately one-third of these readmissions occurred after 6 months, it is imperative to ensure adequate follow-up and treatment for postpartum IBD patients, particularly in the extended postpartum period.

Racial and Ethnic Disparities in Peripartum Hysterectomy Risk and Outcomes.

OBJECTIVE: This study aimed to determine whether race and ethnicity contribute to risks associated with peripartum hysterectomy. STUDY DESIGN: This retrospective cross-sectional study utilized the 2000-2014 Nationwide Inpatient Sample to analyze risk of peripartum hysterectomy and associated severe maternal morbidity, mortality, surgical injury, reoperation, surgical-site complications, and mortality by maternal race and ethnicity. Race and ethnicity were categorized as non-Hispanic white, non-Hispanic black, Hispanic, other, and unknown. Multivariable log-linear regression models including patient, clinical, and hospital risk factors were performed with adjusted risk ratios (aRRs) and 95% confidence intervals (CIs). RESULTS: Of 59,854,731 delivery hospitalizations, there were 45,369 peripartum hysterectomies (7.6 per thousand). Of these, 37.8% occurred among non-Hispanic white, 13.9% among non-Hispanic black, and 22.8% among Hispanic women. In adjusted analyses, non-Hispanic black (aRR: 1.21, 95% CI: 1.17-1.29) and Hispanic women (aRR: 1.25, 95% CI: 1.22-1.29) were at increased risk of hysterectomy compared with non-Hispanic white women. Risk for severe morbidity was increased for non-Hispanic black (aRR: 1.25, 95% CI: 1.19-1.33), but not for Hispanic (aRR: 1.02, 95% CI: 0.97-1.07) women. Between these three groups, risk for intraoperative complications was highest among non-Hispanic white women, risk for reoperation was highest among Hispanic women, and risk for surgical-site complications was highest among non-Hispanic black women. Evaluating maternal mortality, non-Hispanic black women (RR: 3.83, 95% CI: 2.65-5.53) and Hispanic women (RR: 2.49, 95% CI: 1.74-3.59) were at higher risk than non-Hispanic white women. CONCLUSION: Peripartum hysterectomy and related complications other than death differed modestly by race. In comparison, mortality differentials were large supporting that differential risk for death in the setting of this high-risk scenario may be an important cause of disparities. KEY POINTS: · Peripartum hysterectomy and related complications differed modestly by race.. · Mortality differentials in the setting of peripartum hysterectomy were large.. · Failure to rescue may be an important cause of peripartum hysterectomy disparities..

Services and payer mix of Black-serving hospitals and related severe maternal morbidity.

BACKGROUND: Black-serving hospitals are associated with increased maternal risk. However, prior administrative data research on maternal disparities has generally included limited hospital factors. More detailed evaluation of hospital factors related to obstetric outcomes may be important in understanding disparities. OBJECTIVE: To examine detailed characteristics of Black-serving hospitals and how these characteristics are associated with risk for severe maternal morbidity (SMM). METHODS: This serial cross-sectional study linked the 2010-2011 Nationwide Inpatient Sample and the 2013 American Hospital Association Annual Survey Databases. Delivery hospitalizations occurring to women 15-54 years of age were identified. The proportions of non-Hispanic Black patients within a hospital was categorized into quartiles, and hospital factors such as specialized medical, surgical and safety-net services as well as payer mix were compared across these quartiles. A series of models was performed evaluating risk for SMM with Black-serving hospital quartile as the primary exposure. Log linear regression models with a Poisson distribution (and robust variance) were performed with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CIs) as measures of effect. RESULTS: Overall 965,202 deliveries from 430 hospitals met inclusion criteria and were included in the analysis. By quartile, non-Hispanic Black patients accounted for 1.3%, 5.4%, 13.4%, and 33.8% of patients. Many services were significantly less common in the lowest compared to the highest Black-serving hospital quartile including cardiac intensive care (48.9% versus 74.5%), neonatal intensive care (28.9% versus 64.9%), pediatric intensive care (20.0% versus 45.7%), pediatric cardiology (29.6% versus 44.7%), and HIV/AIDS services (36.3% versus 71.3%) (p≤0.01 for all). Indigent care clinics, crisis prevention, and enabling services (p≤0.01 for all) were more common at Black-serving hospitals as was Medicaid payer. Following adjustments for detailed hospital factors, the lowest Black serving hospital quartile carried the lowest risk for SMM. However, SMM risks were similar across the 2nd (aRR 1.31, 95% CI 1.08, 1.59), 3rd (aRR 1.27, 95% 1.05, 1.55), and 4th (aRR 1.29, 95% CI 1.07, 1.55) quartiles. CONCLUSION: Black-serving hospitals were more likely to provide a range of specialized medical, surgical, and safety-net services and to have a higher Medicaid burden. Payer mix and unmeasured confounding may account for some of the maternal risk associated with Black-serving hospitals.

Risk for and disparities in critical care during delivery hospitalizations.

BACKGROUND: Need for critical care during delivery hospitalizations may be an important maternal outcome measure, but it is not well characterized. OBJECTIVE: This study aimed to characterize the risks and disparities in critical care diagnoses and interventions during delivery hospitalizations. STUDY DESIGN: This serial cross-sectional study used the 2000-2014 National Inpatient Sample. Here, the primary outcome was a composite of critical care interventions and diagnoses, including mechanical ventilation and intubation, central monitoring, septicemia, coma, acute cerebrovascular disease, extracorporeal membrane oxygenation, Swan-Ganz catheter monitoring, cardiac rhythm conversion, and respiratory failure. Temporal trends, risk of death, and the proportion of deaths with a critical care composite diagnosis were determined. Unadjusted and adjusted log-linear regression models were fit with a critical care composite as the outcome, adjusting for demographic, clinical, and hospital factors. To evaluate the role of critical care interventions in disparities, analyses were stratified by maternal race and ethnicity. RESULTS: Of 45.8 million deliveries identified, 0.21% had a critical care procedure or diagnosis during the delivery hospitalization. Overall, 75.8% of maternal deaths had an associated diagnosis from a critical care composite. The critical composite increased from 17.9 to 30.3 per 10,000 deliveries from 2000 to 2014 with an average annual percentage change of 3.4% (95% confidence interval, 1.3-5.5). Mechanical ventilation and intubation (21.5% of cases) and respiratory failure (54.8% of cases) were the most common diagnoses present in the composite. Although non-Hispanic black women were at 32.4% higher risk than non-Hispanic white women to die in the setting of a critical care diagnosis (2.2% vs 1.7%; P<.01), they were 162% more likely to have a critical care diagnosis (risk ratio, 2.62; 95% confidence interval, 2.58-2.66). Of clinical factors, primary cesarean delivery (adjusted relative risk, 7.54; 95% confidence interval, 7.43-7.65), postpartum hemorrhage (adjusted relative risk, 5.11; 95% confidence interval, 5.02-5.19), and chronic kidney disease (adjusted relative risk, 4.06; 95% confidence interval, 3.89-4.23) were associated with the highest adjusted risk of a critical care composite. CONCLUSION: Three-quarters of maternal deaths were associated with a critical care diagnosis or procedure. The rate of critical care during delivery hospitalizations increased over the study period. Maternal mortality disparities may result from risks of conditions that require critical care rather than the care received once a critical care condition has developed.

Hospital Safety-Net Burden and Risk for Readmissions and Severe Maternal Morbidity.

OBJECTIVE: This study aimed to analyze whether hospital safety-net burden status is associated with increased risk for severe maternal morbidity (SMM) and postpartum readmissions. STUDY DESIGN: The 2010 to 2014 Nationwide Readmissions Database was utilized for this retrospective cohort study. Hospitals were categorized as high-burden hospitals (25% of hospitals with the highest safety-net burden), medium-burden hospitals (50% of hospitals with intermediate safety-net burden), and low-burden hospitals (25% of hospitals with the lowest safety-net burden) based on the proportions of Medicaid or uninsured patients. Risk for (1) SMM, (2) 60-day postpartum readmissions, and (3) SMM during postpartum readmissions was analyzed. Unadjusted and adjusted log-linear regression models were performed, respectively, for these outcomes with unadjusted risk ratio (RR) and adjusted RR (aRR) as measures of effect. Adjusted models included demographic, hospital, and clinical factors. RESULTS: High-burden safety-net status was associated with increased risk for SMM compared with low-burden safety-net status in both unadjusted (RR: 1.51, 95% confidence interval [CI]: 1.50-1.53) and adjusted analyses (aRR: 1.27, 95% CI: 1.25-1.30). High-burden status was also associated with increased risk for readmissions in unadjusted analyses (RR: 1.42, 95% CI: 1.40-1.44), although this risk was attenuated in adjusted analyses (aRR: 1.07, 95% CI: 1.06-1.08). High-burden status was associated with significantly increased risk for readmission for uterine infections, hypertensive diseases of pregnancy, and psychiatric diagnoses. High-burden status was not associated with severe morbidity during readmissions in adjusted or unadjusted analyses (RR: 1.02, 95% CI: 0.98-1.05; aRR: 0.95, 95% CI: 0.92-0.99). CONCLUSION: This study found that high safety-net burden hospitals may be a higher risk setting for obstetric care. Improvement of outcomes in high-burden settings may be important in overall efforts to reduce maternal risk.

Postpartum Psychiatric Admissions in the United States.

OBJECTIVE: This study aimed to assess risk for postpartum psychiatric admissions in the United States. STUDY DESIGN: This study used the 2010 to 2014 Nationwide Readmissions Database to identify psychiatric admissions during the first 60 days after delivery hospitalization. Timing of admission after delivery discharge was determined. We fit multivariable log-linear regression models to assess the impact of psychiatric comorbidity on admission risk, adjusting for patient, obstetrical, and hospital factors. RESULTS: Of 15.7 million deliveries from 2010 to 2014, 11,497 women (0.07%) were readmitted for a primary psychiatric diagnosis within 60 days postpartum. Psychiatric admissions occurred relatively consistently across 10-day periods after delivery hospitalization discharge. Psychiatric diagnoses were present among 5% of women at delivery but 40% of women who were readmitted postpartum for a psychiatric indication. In the adjusted model, women with psychiatric diagnoses at delivery hospitalization were 9.7 times more likely to be readmitted compared with those without psychiatric comorbidity. Women at highest risk for psychiatric admission were those with Medicare and Medicaid, in lower income quartiles, and of younger age. CONCLUSION: While a large proportion of psychiatric admissions occurred among a relatively small proportion of at-risk women, admissions occurred over a broad temporal period relative to other indications for postpartum admission.

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

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

Fragmentation of postpartum readmissions in the United States.

BACKGROUND: Fragmentation of care, wherein a patient is readmitted to a hospital different from the initial point of care, has been shown to be associated with worse patient outcomes in other medical specialties. However, postpartum fragmentation of care has not been well characterized in obstetrics. OBJECTIVE: To characterize risk for and outcomes associated with fragmentation of postpartum readmissions wherein the readmitting hospital is different than the delivery hospital. METHODS: The 2010 to 2014 Nationwide Readmissions Database was used for this retrospective cohort study. Postpartum readmissions within 60 days of delivery hospitalization discharge for women aged 15-54 years were identified. The primary outcome, fragmentation, was defined as readmission to a different hospital than the delivery hospital. Hospital, demographic, medical, and obstetric factors associated with fragmented readmission were analyzed. Adjusted log-linear models were performed to analyze risk for readmission with adjusted risk ratios and 95% confidence intervals as the measures of effect. The associations between fragmentation and secondary outcomes including (1) length of stay >90th percentile, (2) hospitalization costs >90th percentile, and (3) severe maternal morbidity were determined. Whether specific indications for readmission such as hypertensive diseases of pregnancy, wound complications, and other conditions were associated with higher or lower risk for fragmentation was analyzed. RESULTS: From 2010 to 2014, 141,276 60-day postpartum readmissions were identified, of which 15% of readmissions (n = 21,789) occurred at a hospital different from where the delivery occurred. Evaluating individual readmission indications, fragmentation was less likely for hypertension (11.1%), wound complications (10.7%), and uterine infections (11.0%), and more likely for heart failure (28.6%), thromboembolism (28.4%), and upper respiratory infections (33.9%) (P < .01 for all). In the adjusted analysis, factors associated with fragmentation included public insurance compared to private insurance (Medicare: adjusted risk ratio, 1.68; 95% confidence interval, 1.52, 1.86; Medicaid: adjusted risk ratio, 1.28; 95% confidence interval, 1.24, 1.32). Fragmentation was associated with increased risk for severe maternal morbidity during readmissions in both unadjusted (relative risk, 1.84; 95% confidence interval, 1.79, 1.89) and adjusted (adjusted risk ratio, 1.81; 95% confidence interval, 1.76, 1.86) analyses. In adjusted analyses, fragmentation was also associated with increased risk for length of stay >90th percentile (relative risk, 1.48; 95% confidence interval, 1.42-1.54) and hospitalization costs >90th percentile (adjusted risk ratio, 1.74; 95% confidence interval, 1.67, 1.81). CONCLUSION: This study of nationwide estimates of postpartum fragmentation found discontinuity of postpartum care was associated with increased risk for severe morbidity, high costs, and long length of stay. Reduction of fragmentation may represent an important goal in overall efforts to improve postpartum care.

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

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

Postpartum length of stay and risk for readmission among women with preeclampsia.

Objective: How hospital length of stay after delivery for women with preeclampsia is associated with risk for readmission is unknown. The objective of this study was to evaluate risk for 60-day hypertension-related postpartum readmission based on length of stay after delivery.Methods: The 2014 Healthcare Cost and Utilization Project's (HCUP) Nationwide Readmissions Database was used to analyze risk for readmission for a hypertension-related diagnosis within 60 days from cesarean delivery hospitalization for women with preeclampsia who underwent cesarean delivery. Risk for readmission was evaluated based on postoperative length of stay as well as demographic, hospital, and other obstetric factors. Population weights were applied to create national estimates. Multivariable analyses were performed with adjusted risk ratios (aRR) and corresponding 95% confidence intervals as measures of effect. Mean and median hospital charges based upon postoperative length of stay were also evaluated. Time from delivery hospitalization to readmission was calculated.Results: In 2014, 65 401 women with preeclampsia underwent cesarean delivery. Of these, 1016 women (1.6%) were readmitted for a hypertension-related diagnosis. 921 of the 1016 readmissions occurred within 10 days of discharge (90.6%). In adjusted analyses, postoperative LOS 5-7 days and >7 days compared to LOS <3 days were associated with decreased risk of 60-day hypertension-related readmission (aRR 0.59 95% CI 0.45, 0.78; aRR 0.53 95% CI 0.29, 1.00, respectively). When the cohort was restricted to women with severe preeclampsia or eclampsia, LOS 5-7 days was associated with decreased risk of 60-day hypertension-related readmission in both unadjusted and adjusted analyses compared to LOS <3 days (risk ratios (RR) 0.34, 95% CI 0.18, 0.65; aRR 0.29, 95% 0.18, 0.46, respectively). Median delivery hospitalization charges were $26 512. Compared to LOS <3 days, mean and median charges increased significantly for patients with LOS 4, 5-7, and >7 days.Conclusion: Longer postoperative length of stay during cesarean delivery hospitalizations was associated with decreased risk for postpartum hypertension-related readmission. Most readmissions occurred soon after discharge. These findings support that post-delivery management may play a role in likelihood of women requiring subsequent readmission for complications related to preeclampsia after discharge.

Early Readmission After Ventricular Shunting in Adults with Hydrocephalus: A Nationwide Readmission Database Analysis.

BACKGROUND: Ventricular shunting is one of the primary modalities for addressing hydrocephalus in both children and adults. Despite advances in shunt technology and surgical practices, shunt failure is a persistent challenge for neurosurgeons, and shunt revisions account for a substantial proportion of all shunt-related procedures. There are a wealth of studies elucidating failure patterns and patient demographics in pediatric cohorts; however, data in adults are less uniform. We sought to determine the rates of all-cause and shunt failure readmission in adults who underwent the insertion of a ventricular shunt. METHODS: We queried the Nationwide Readmissions Database from 2010 to 2014 to evaluate new ventricular shunts placed in adults with hydrocephalus. We sought to determine the rates of all-cause and shunt revision-related readmissions and to characterize factors associated with readmissions. We analyzed predictors including patient demographics, hospital characteristics, shunt type, and hydrocephalus cause. RESULTS: Analysis included 24,492 initial admissions for shunt placement in patients with hydrocephalus. Of patients, 9.17% required a shunt revision within the first 6 months; half of all revisions occurred within the first 41 days. There were 4044 (16.50%) 30-day and 5758 (28.8%) 90-day all-cause readmissions. In multivariable analysis, patients with a ventriculopleural shunt, Medicare insurance, and younger age had increased likelihood for shunt revision. Notable predictors for all-cause readmission were insurance type, length of hospitalization, age, comorbidities, and hydrocephalus cause. CONCLUSIONS: Most shunt revisions occurred during the first 2 months. Readmissions occurred frequently. We identified patient factors that were associated with all-cause and shunt failure readmissions.

Hypertensive Postpartum Admissions Among Women Without a History of Hypertension or Preeclampsia.

OBJECTIVE: To analyze risk factors, temporality, and outcomes for women readmitted postpartum for a hypertensive indication who did not have a hypertensive diagnosis during their delivery hospitalization. METHODS: The Healthcare Cost and Utilization Project's Nationwide Readmissions Database for 2010-2014 was used to evaluate risk for postpartum readmission for preeclampsia and hypertension within 60 days of discharge from a delivery hospitalization among women without these diagnoses during delivery in this cohort study. Obstetric, medical, demographic, and hospital factors associated with postpartum readmission were analyzed. Both unadjusted and adjusted analyses were performed. Risk was characterized as unadjusted and adjusted risk ratio with 95% CI. As a secondary outcome, risk for severe maternal morbidity during readmissions was also evaluated comparing women with and without hypertensive diagnoses during their delivery hospitalization. RESULTS: Among delivery hospitalizations without a hypertensive diagnosis at delivery, absolute rates of readmission within 60 days for a hypertensive indication were low, with one readmission occurring per 687 deliveries for all women. The rate rose to 1 in 498 among women 35-39 years of age, 1 in 337 for women 40-54, 1 in 601 for women with Medicaid, 1 in 506 for women with Medicare, 1 in 497 with cesarean delivery, 1 in 600 with postpartum hemorrhage, 1 in 455 and 1 in 378 for gestational and pregestational diabetes, respectively, 1 in 428 for asthma, 1 in 225 for chronic kidney disease, and 1 in 214 for lupus. For the secondary outcome, risk for severe maternal morbidity was higher for women without a hypertensive indication during their delivery compared with women with a diagnosis (12.1% vs 6.9%, P<.01). CONCLUSION: Risk for hypertensive postpartum readmissions for women without delivery-hospitalization preeclampsia or hypertension is low. Future comparative effectiveness and clinical research is indicated to determine whether earlier postpartum identification of elevated blood pressure followed by increased surveillance and counseling may further reduce risk.

Life-threatening complications among women with severe ovarian hyperstimulation syndrome.

BACKGROUND: Ovarian hyperstimulation syndrome is a potentially life-threatening clinical condition. OBJECTIVE: The objective of this study was to evaluate risk factors for life-threatening complications for patients with severe ovarian hyperstimulation syndrome in a United States nationwide sample. MATERIALS AND METHODS: Ovarian hyperstimulation syndrome admissions from 2002 to 2011 from the Nationwide Inpatient Sample were included in this study. The association between patient and hospital factors and life-threatening complications (deep vein thrombosis/pulmonary embolism, acute respiratory distress syndrome, acute renal failure, intubation), nonroutine discharge (discharge to skilled nursing facility, transfer hospital), prolonged length of stay, and total hospital charges were analyzed. Survey-adjusted multivariable logistic regression analyses were performed for these outcomes, controlling for risk factors, with adjusted odds ratios with 95% confidence intervals as the measures of effect. RESULTS: A total of 11,562 patients were hospitalized with severe ovarian hyperstimulation syndrome from 2002 to 2011. The majority were white (55.7%), with private insurance (87.7%), aged 25-39 years (84.6%), and hospitalized in an urban location (95%). In all, 19.3% of patients had medical comorbidities including hypertension, diabetes, obesity, hypothyroidism, and anemia. Life-threatening complications occurred in 4.4% of patients (deep vein thrombosis/pulmonary embolism, 2.2%; acute renal failure; acute respiratory distress syndrome, 0.9%; intubation, 0.5%). Patients ≥40 years old (odds ratio, 4.02; 95% confidence interval, 1.37, 11.76), those with comorbidities (odds ratio, 2.29; 95% confidence interval, 1.46, 3.57), and African American patients (odds ratio, 2.15; 95% confidence interval, 1.25, 3.70) were more likely to develop life-threatening conditions. Patients with medical comorbidities (odds ratio, 0.39; 95% confidence interval, 0.24, 0.63) were also less likely to be routinely discharged from the hospital. Adjusting for patient and hospital demographics, patients with comorbidities were more likely to develop deep vein thrombosis/pulmonary embolism (adjusted odds ratio, 2.44; 95% confidence interval, 1.28, 4.65) and acute renal failure (adjusted odds ratio, 2.26; 95% confidence interval, 1.21, 4.23). Patients who developed life-threatening complications had longer hospital length of stay (adjusted odds ratio, 3.72; 95% confidence interval, 2.28, 6.07) and higher hospital costs (adjusted odds ratio, 5.20; 95% confidence interval, 3.22,8.39). CONCLUSION: Patients with common medical comorbidities are at higher risk for life-threatening complications in the setting of severe ovarian hyperstimulation syndrome. Furthermore, these complications are associated with high hospital costs and hospital burden. Given the increasing number of in vitro fertilization patients with medical comorbidities, closer monitoring of at-risk patients may be indicated. As assisted reproductive technology practice changes in recent years with strategies designed to reduce ovarian hyperstimulation syndrome risk, future studies are needed to assess the impact of these changes on hospitalization and complication risk.

Increased Hospital Surgical Volume Reduces Rate of 30- and 90-Day Readmission After Acoustic Neuroma Surgery.

BACKGROUND: Hospital readmissions are commonly linked to elevated health care costs, with significant financial incentive introduced by the Affordable Care Act to reduce readmissions. OBJECTIVE: To study the association between patient, hospital, and payer factors with national rate of readmission in acoustic neuroma surgery. METHODS: All adult inpatients undergoing surgery for acoustic neuroma in the newly introduced Nationwide Readmissions Database from 2013 to 2014 were included. We identified readmissions for any cause with a primary diagnosis of neurological, surgical, or systemic complication within 30- and 90-d after undergoing acoustic neuroma surgery. Multivariable models were employed to identify patient, hospital, and administrative factors associated with readmission. Hospital volume was measured as the number of cases per year. RESULTS: We included patients representing a weighted estimate of 4890 admissions for acoustic neuroma surgery in 2013 and 2014, with 355 30-d (7.7%) and 341 90-d (9.1%) readmissions. After controlling for patient, hospital, and payer factors, procedural volume was significantly associated with 30-d readmission rate (OR [odds ratio] 0.992, p = 0.03), and 90-d readmission rate (OR 0.994, p = 0.047). The most common diagnoses during readmission in both 30- and 90-d cohorts included general central nervous system complications/deficits, hydrocephalus, infection, and leakage of cerebrospinal fluid (rhinorrhea/otorrhea). CONCLUSION: After controlling for patient, hospital, and payer factors, increased procedural volume is associated with decreased 30- and 90-d readmission rate for acoustic neuroma surgery. Future studies seeking to improve outcomes and reduce cost in acoustic neuroma surgery may seek to further evaluate the role of hospital procedural volume and experience.

Predictors of Surgical Site Infection After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis.

OBJECTIVE: Surgical site infections (SSIs) carry significant patient morbidity and mortality and are a major source of readmissions after craniotomy. Because of their deleterious effects on health care outcomes and costs, identifying modifiable risk factors holds tremendous value. However, because SSIs after craniotomy are rare and most existing data comprise single-institution studies with small sample sizes, many are likely underpowered to discern for such factors. The objective of this study was to use a large hetereogenous patient sample to determine SSI incidence after nonemergent craniotomy and identify factors associated with readmission and subsequent need for wound washout. METHODS: We used the 2010-2014 Nationwide Readmissions Database cohorts to discern for factors predictive of SSI and washout. RESULTS: We identified 93,920 nonemergent craniotomies. There were 2079 cases of SSI (2.2%) and 835 reoperations for washout (0.89%) within 30 days of index admission and there were 2761 cases of SSI (3.6%) and 1220 reoperations for washout (1.58%) within 90 days. Several factors were predictive of SSI in multivariate analysis, including tumor operations, external ventricular drain (EVD), age, length of stay, diabetes, discharge to an intermediate-care facility, insurance type, and hospital bed size. Many of these factors were similarly implicated in reoperation for washout. CONCLUSIONS: SSI incidence in neurosurgery is low and most readmissions occur within 30 days. Several factors predicted SSI after craniotomy, including operations for tumor, younger age, hospitalization length, diabetes, discharge to institutional care, larger hospital bed size, Medicaid insurance, and presence of an EVD. Diabetes and EVD placement may represent modifiable factors that could be explored in subsequent prospective studies for their associations with cranial SSIs.

Timing and Risk Factors of Postpartum Stroke.

OBJECTIVE: To characterize risk and timing of postpartum stroke readmission after delivery hospitalization discharge. METHODS: The Healthcare Cost and Utilization Project's Nationwide Readmissions Database for calendar years 2013 and 2014 was used to perform a retrospective cohort study evaluating risk of readmission for stroke within 60 days of discharge from a delivery hospitalization. Risk was characterized as odds ratios (ORs) with 95% CIs based on whether patients had hypertensive diseases of pregnancy (gestational hypertension or preeclampsia), or chronic hypertension, or neither disorder during the index hospitalization. Adjusted models for stroke readmission risk were created. RESULTS: From January 1, 2013, to October 31, 2013, and January 1, 2014, to October 31, 2014, 6,272,136 delivery hospitalizations were included in the analysis. One thousand five hundred five cases of readmission for postpartum stroke were identified. Two hundred fourteen (14.2%) cases of stroke occurred among patients with hypertensive diseases of pregnancy, 66 (4.4%) with chronic hypertension, and 1,225 (81.4%) without hypertension. The majority of stroke readmissions occurred within 10 days of hospital discharge (58.4%), including 53.2% of patients with hypertensive diseases of pregnancy during the index hospitalization, 66.7% with chronic hypertension, and 58.9% with no hypertension. Hypertensive diseases of pregnancy and chronic hypertension were associated with increased risk of stroke readmission compared with no hypertension (OR 1.74, 95% CI 1.33-2.27 and OR 1.88, 95% CI 1.19-2.96, respectively). Median times to readmission were 8.9 days for hypertensive diseases of pregnancy, 7.8 days for chronic hypertension, and 8.3 days without either condition. CONCLUSION: Although patients with chronic hypertension and hypertensive diseases of pregnancy are at higher risk of postpartum stroke, they account for a minority of such strokes. The majority of readmissions for postpartum stroke occur within 10 days of discharge; optimal blood pressure management may be particularly important during this period.