The critical role of phlebolymphedema in cellulitis associated with lymphedema: Its incidence and economic impact in a large real-world population.

OBJECTIVE: The aims of this study were: to define the incidence of cellulitis in patients with lymphedema (LED) overall and relate this to the etiology of LED; to determine how this rate might be affected by recurrence of cellulitis; and to quantify the contemporary economic burden of treatment. Understanding these factors is essential in developing targeted cellulitis prevention strategies and reducing health care costs. METHODS: The IBM MarketScan Research Database was examined from April 2013 to March 2019 for patients with a new diagnosis of LED (n = 85,601). Based on International Classification of Diseases (ICD)-9/ICD-10 diagnosis codes, the incidence and cost of cellulitis were ascertained during the 3-year follow-up period. Incidence rates (per 100 patient-years [PYs]) and cost (per patient per year) of cellulitis were evaluated among all patients with LED and within subgroups of LED etiologies. RESULTS: Among the three most common morbidities associated with LED (breast cancer-related lymphedema [BCRL], n = 17,954 [20.97%]; gynecological cancer-related LED [GCRL], n = 1256 [1.47%]; and phlebolymphedema [PLED], n = 8406 [9.82%]), rates of cellulitis were markedly lower for BCRL (8.9; 95% confidence interval [CI], 8.7-9.2) and GCRL (14.8; 95% CI, 13.4-16.4) vs PLED (47.7; 95% CI, 46.7-48.8). Patients with a history of cellulitis had markedly higher cellulitis rates during follow-up than those without-overall, 74.0% vs 16.4%; BCRL, 42.9%; 95% CI, 39.7%-46.3% vs 7.6%; 95% CI, 7.3%-7.9%; GCRL, 67.5%; 95% CI, 56.4%-80.8% vs 11.0%; 95% CI, 9.8%-12.4%; and PLED, 81.7%; 95% CI, 79.4%-84.1% vs 30.4%; 95% CI, 29.4%-31.4%, respectively. The mean $/patient/year of cellulitis-related costs for a patient with PLED ($2836; 95% CI, $2395-$3471) was significantly greater than that for BCRL ($503; 95% CI, $212-$1387) and GCRL ($609; 95% CI, $244-$1314). CONCLUSIONS: The incidence of cellulitis associated with LED varies by the etiology of LED. PLED has the highest rates of both an initial cellulitis episode and recurrent cellulitis events. Additionally, PLED has one of the largest cellulitis-related total costs per patient per year. Prevention, as well as early identification and treatment of PLED-associated cellulitis, could significantly decrease health care costs and improve patient quality of life.

Smaller hospital discharge volume and urban area are associated with higher proportional cellulitis discharges.

Cellulitis is commonly misdiagnosed, resulting in increased healthcare costs and complications. There is little published work regarding the relationship between hospital characteristics and cellulitis discharge rates. Here, we performed a cross-sectional analysis of cellulitis inpatient discharges using publicly available national data to examine hospital characteristics associated with higher proportional cellulitis discharge rates. The results of our study showed a strong association of increased proportion of cellulitis discharges in association with hospitals that discharged fewer total patients and a direct association with urban location. The factors that influence hospital cellulitis discharge diagnoses are numerous, and while its overdiagnosis remains a source of medical overspending and complications, our study may provide direction for more focused efforts to increase dermatology care in lower volume hospitals and urban areas.

Impact of the Covid-19 pandemic context on the microbiological epidemiology and management of flexor sheath phlegmons.

INTRODUCTION: The COVID-19 pandemic in France has recently modified the patients' lifestyles, as well as methods of medical and surgical management. This could explain subsequent changes to the microbiological spectrum, the severity, as well as the scalability of phlegmons of the flexor tendon sheath. The objective of this study was to construct an epidemiological and bacteriological inventory of these hand infections, and to compare the clinical and microbiological data, before and after the COVID-19 pandemic. HYPOTHESIS: The hypothesis of this work was that the phlegmons of the flexor tendon sheath presented specific microbiological characteristics in the tropical environment of our University Hospital Center, and that these characteristics could have changed with the recent introduction of hydro-alcoholic solution (HAS) associated to the COVID-19 pandemic. MATERIAL AND METHODS: The preoperative epidemiological data of our patients were collected between January 2016 and December 2020. The stage of severity, according to the classification of Michon, the use of hydro-alcoholic solution, as well as the early clinical evolution were collected. The cohort was then divided into two groups in order to compare the microbiological profiles, the management and the clinical evolution of patients in the pre-COVID period with those in the post-COVID period. RESULTS: A total of 199 patients were included, 154 patients in the pre-COVID period and 26 in the post-COVID period. We found a majority of MSSA (58.3%, N=105) and negative samples comprised 18.9% (N=34). No statistically significant difference was found between the two groups regarding the bacteriological results. The clinical course was judged to be favorable in 93.5% of cases in the pre-COVID group compared to 80.8% in the post-COVID group (p=0.046). The use of HAS (p<0.0001), as well as the initial stage of severity according to Michon, were significantly higher in group 2 (p=0.04). DISCUSSION: The COVID-19 pandemic has not shown any change in the microbiological spectrum, despite the now daily use of HAS in everyday life. The postoperative clinical evolution was significantly less favorable after the onset of COVID and could be explained by an increase in cases with a more advanced initial stage of severity. LEVEL OF EVIDENCE: IV, Observational epidemiological study.

Burden, risk factors, and infectious complications of cellulitis and erysipelas in US adults and children in the emergency department setting.

BACKGROUND: Little is known about the use and burden of emergency department (ED) visits for cellulitis/erysipelas in the United States. OBJECTIVE: To determine the prevalence, risk factors, complications, and cost of emergency care for cellulitis/erysipelas in the United States. METHODS: Cross-sectional study of the 2006 to 2016 National Emergency Department Sample, including a 20% sample of US ED visits (N = 320,080,467). RESULTS: The mean annual incidence of ED visits with a primary diagnosis of cellulitis/erysipelas was 2.42 to 3.55 per million adult and 1.14 to 2.09 per million pediatric ED visits. ED visits for cellulitis/erysipelas decreased significantly from 2006 to 2015 (Rao-Scott chi-square, P < .0001). ED visits with versus without a primary diagnosis of cellulitis/erysipelas were associated with public or no insurance and lower household income quartiles, and were more likely to occur during weekends and summer months. The mean cost of ED visits for cellulitis/erysipelas more than doubled in adults (from $720 to $1680) and tripled in children (from $939 to $2,823) from 2006 to 2016. ED visits for cellulitis/erysipelas were associated with multiple risk factors and increased infectious complications. LIMITATIONS: No data on cellulitis and erysipelas treatment or recurrence. CONCLUSION: There is a substantial and increasing burden of ED visits for cellulitis/erysipelas in the United States. Many ED visits occurred for uncomplicated cellulitis/erysipelas, in part because of health care disparities.

The economic and health burdens of diseases caused by group A Streptococcus in New Zealand.

OBJECTIVES: In preparation for the future arrival of a group A Streptococcus (GAS) vaccine, this study estimated the economic and health burdens of GAS diseases in New Zealand (NZ). METHODS: The annual incidence of GAS diseases was based on extrapolation of the average number of primary healthcare episodes managed each year in general practices (2014-2016) and on the average number of hospitalizations occurring each year (2005-2014). Disease incidence was multiplied by the average cost of diagnosing and managing an episode of disease at each level of care to estimate the annual economic burden. RESULTS: GAS affected 1.5% of the population each year, resulting in an economic burden of 29.2 million NZ dollars (2015 prices) and inflicting a health burden of 2373 disability-adjusted life years (DALYs). Children <5 years of age were the most likely age group to present for GAS-related healthcare. Presentations for superficial throat and skin infections (predominantly pharyngitis and impetigo) were more common than other GAS diseases. Cellulitis contributed the most to the total economic and health burdens. Invasive and immune-mediated diseases disproportionately contributed to the total economic and health burdens relative to their frequency of occurrence. CONCLUSION: Preventing GAS diseases would have substantial economic and health benefits in NZ and globally.

An Epidemiological Analysis of Pediatric Dog Bite Injuries Over a Decade.

BACKGROUND: An estimated 800,000 dog bites require medical attention every year. The purpose of this study is to review the characteristics of dog bite injuries in children and examine temporal trends. METHODS: The Kids' Inpatient Database was used to identify pediatric patients with dog bite injuries over a 10-y period. Demographic data, primary payer, injury characteristics, length of hospitalization, and treatments were recorded. Statistical analysis was performed in SAS 9.3 (SAS Institute Inc, Cary, NC). RESULTS: A total of 6308 patients were identified. Average age at time of injury was 6.4 ± 4.3 y. Children under age 5 y were the most affected subgroup (39.3% in 2000 versus 44.7% in 2009, P < 0.001). Most bites were to the head/neck and significantly increased from 53.9% in 2000 to 60.1% in 2009. Cellulitis complicated many injuries (33.7% in 2000 versus 44.8% in 2009, P < 0.001). Overall, 50% of patients underwent a procedure; 31% had an invasive surgical procedure; and 5.1% of patients required skin grafts or flaps. CONCLUSIONS: Dog bites are a common cause of pediatric injuries and are a significant burden on families and the health care system. Evaluating the characteristics of these injuries can guide educational efforts.

Clinical features, microbiological epidemiology and recommendations for management of cellulitis in extremity lymphedema.

BACKGROUND: This high volume, single center study investigated the prevalence, bacterial epidemiology, and responsiveness to antibiotic therapy of cellulitis in extremity lymphedema. METHODS: From 2003 to 2018, cellulitis events from a cohort of 420 patients with extremity lymphedema were reviewed. Demographics, lymphedema grading, symptoms, inflammatory markers, cultures and antibiotic therapy regimens were compiled from cellulitis episodes data. Univariate and multivariate analyses were performed for detailed analysis. RESULTS: A total of 131 separate episodes of cellulitis were recorded from 43 (81.1%) lower limb and 10 (19.9%) upper limb lymphedema patients. The prevalence and recurrence rates for cellulitis in lymphedema patients were 12.6% (53 of 420) and 56.6% (30 of 53), respectively. The most common findings were increased limb circumference (127 of 131; 96.9%) and abnormal C-reactive protein (CRP) level (86 of 113; 76.1%). Blood cultures were obtained in 79 (60.3%) incidents, with 9 (11.4%) returning positive. Streptococcus agalactiae was the most isolated bacterium (5 of 9; 55.5%). CONCLUSIONS: The cellulitis prevalence and recurrence rate in extremity lymphedema were 12.6%, and 56.6%, respectively. Strongest indicators of cellulitis were increased affected limb circumference and elevated CRP level. Empiric antibiotic therapy began with coverage for Steptococcus species before broadening to anti-Methicillin-resistant Staphylococcus aureus and anti-Gram negatives if needed for effective treatment of extremity lymphedema cellulitis.

Prevalence and Trends in Obesity Among Hospitalized Children.

OBJECTIVES: As obesity rates rise in children, it is likely that the number of hospitalized children with obesity is also increasing. However, characterization of the inpatient population with obesity as a whole has not been reported. We aimed to examine trends in the annual prevalence of obesity in hospitalized children and to identify demographic and clinical characteristics associated with higher obesity prevalence in children who are hospitalized. METHODS: We completed a retrospective cohort analysis of children aged 2 to 19 years admitted to a single tertiary children's hospital system for any reason in 2009-2016. Body mass index was calculated from documented height and weight. Children with obesity were defined by using age- and sex-specific body mass index percentile guidelines established by the Centers for Disease Control and Prevention. Annual obesity prevalence was calculated on the encounter level for service line and All Patients Refined Diagnosis-Related Groups (diagnosis groups). χ2 tests were used to determine statistical differences between groups, and the Cochran-Armitage test of trend was used to describe changes in obesity over time. RESULTS: Of 83 329 children who were hospitalized, 17.0% had obesity, increasing from 16.5% of hospitalizations in 2009-2010 to 17.3% in 2015-2016 (P = .002). Service lines with the highest obesity prevalence included orthopedics (22.1%), infectious disease (20.6%), and neuroscience (18.7%). Diagnosis groups with the highest obesity prevalence included cellulitis (22.5%), tonsil/adenoid procedures (22.0%), and some orthopedic procedures (28.7%). CONCLUSIONS: Some groups of children who were hospitalized experience higher obesity prevalence, including children hospitalized with orthopedic, infectious disease, and neurologic problems. In future research, investigators should target disproportionately affected groups by examining health outcomes, patient safety, and satisfaction issues.

Analysis of Readmissions Following Hospitalization for Cellulitis in the United States.

Importance: Cellulitis commonly results in hospitalization. Limited data on the proportion of cellulitis admissions associated with readmission are available. Objective: To characterize the US national readmission rate associated with hospitalization for treatment of cellulitis. Design, Setting, and Participants: This retrospective cohort analysis of cellulitis admissions from the nationally representative 2014 Nationwide Readmissions Database calculated readmission rates for all cellulitis admissions and subsets of admissions. The multicenter population-based cohort included adult patients admitted for conditions other than obstetrical or newborn care. Data were collected from January 1 through November 30, 2014, and analyzed from February 1 through September 18, 2018. Bivariate logistic regression models were used to assess differences in readmission rates by patient characteristics. Costs were calculated for all readmissions after discharge from hospitalization for cellulitis (hereinafter referred to as cellulitis discharge) and by readmission diagnosis. Exposures: Admission with a primary diagnosis of cellulitis. Main Outcomes and Measures: Proportion of cellulitis admissions associated with nonelective readmission within 30 days, characteristics of patients readmitted after cellulitis discharge, and costs associated with cellulitis readmission. Results: A total of 447 080 (95% CI, 429 927-464 233) index admissions with a primary diagnosis of cellulitis (53.8% male [95% CI, 53.5%-54.2%]; mean [SD] age, 56.1 [18.9] years) were included. Overall 30-day all-cause nonelective readmission rate after cellulitis discharge was 9.8% (95% CI, 9.6%-10.0%). Among patients with cellulitis, age (odds ratio for 45-64 years, 0.78; 95% CI, 0.75-0.81; P = .001) and insurance status (odds ratio for Medicare, 2.45; 95% CI, 2.33-2.58; P < .001) were associated with increased readmission rates. The most common diagnosis of readmissions included skin and subcutaneous tissue infections. The total cost associated with nonelective readmissions attributed to skin and subcutaneous infections within 30 days of a cellulitis discharge during the study period was $114.4 million (95% CI, $106.8-$122.0 million). Conclusions and Relevance: Readmission after hospitalization for cellulitis is common and costly and may be preventable with improved diagnostics, therapeutics, and discharge care coordination.

Skin and soft tissue infections, active component, U.S. Armed Forces, 2013-2016.

During the 4-year surveillance period, there were 282,571 incident cases of skin and soft tissue infection (SSTI) among active component U.S. military members diagnosed in inpatient or outpatient settings, corresponding to an overall incidence of 558.2 per 10,000 person-years (p-yrs). An additional 10,904 cases occurred in theater of operations (460.0 per 10,000 p-yrs). Approximately half (49.4%) were classified as "other SSTI" (e.g., folliculitis, impetigo); 45.9% were cellulitis/abscess; 4.6% were carbuncles/furuncles; and 0.1% were erysipelas. Annual incidence rates declined by 46.6% over the surveillance period. In general, higher rates of SSTIs were associated with younger age, recruit trainee status, and junior enlisted rank. During the surveillance period, 238,924 service members were treated for SSTIs in outpatient or inpatient settings, which accounted for 395,361 medical encounters and 19,213 hospital bed days. The history of operational significance of skin infections in the military, the high healthcare costs associated with evaluating and treating skin infections, and the risk of infections by antibiotic-resistant organisms highlight the importance of prevention, early diagnosis, and definitive treatment of skin infections, particularly in high-risk settings such as new recruit/basic training populations.

The Burden of Facial Cellulitis Leading to Inpatient Hospitalization.

PURPOSE: The purpose of the present study was to present nationally representative estimates of hospitalizations primarily attributed to facial cellulitis and to conduct an exploratory analysis on identifying factors associated with outcomes, such as hospital charges, length of stay (LOS), disposition status, and occurrence of infectious complications. MATERIALS AND METHODS: The present study is a retrospective analysis of the Nationwide Inpatient Sample (NIS) for 2012 and 2013. The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of "682.0" in the primary diagnosis field of NIS (reason for hospitalization) was used to identify cases with facial cellulitis. All patients at least 18 years old who were hospitalized for facial cellulitis were included. Outcome variables examined in the present study were hospital charges, LOS, disposition status, and occurrence of infectious complications. Descriptive statistics and a multivariable linear regression model were used to examine association between independent variables and patient disposition and infectious complications. RESULTS: In 2012 and 2013, 74,480 hospitalizations involved facial cellulitis in adults at least 18 years old in the United States. Most were women (mean age, 47.5 yr). Most patients were routinely discharged home. Age was associated with an increase in odds of discharge to another facility. Variables associated with decreased odds of bacterial infections were age and black or Hispanic race. Women with at least 1 comorbidity had higher odds of mycoses. Statistically relevant predictors of longer than average LOS were age, race, insurance, presence of sepsis, and location. CONCLUSIONS: This study presented nationally representative estimates of hospitalizations attributed primarily to facial cellulitis in the adult population in the United States in 2012 and 2013. The presence of a comorbid condition predicted worse outcomes. Public health efforts should focus on targeting high-risk patients and providing monitoring or early treatment of face cellulitis.

Who Can Have Parenteral Antibiotics at Home?: A Prospective Observational Study in Children with Moderate/Severe Cellulitis.

BACKGROUND: The benefits of treating children at home or in an ambulatory setting have been well documented. We aimed to describe the characteristics and evaluate the outcomes of children with moderate/severe cellulitis treated at home with intravenous (IV) ceftriaxone via direct referral from the Emergency Department to a hospital-in-the-home (HITH) program. METHODS: Patients aged 3 months to 18 years with moderate/severe cellulitis referred from a tertiary pediatric Emergency Department to HITH from September 2012 to January 2014 were prospectively identified. Data collection included demographics, clinical features, microbiological characteristics and outcomes. To ensure home treatment did not result in inferior outcomes, these patients were retrospectively compared with patients who were hospitalized for IV flucloxacillin, the standard-of-care over the same period. The primary outcome was home treatment failure necessitating hospital admission. Secondary outcomes included antibiotic changes, complications, length of stay and cost. RESULTS: Forty-one (28%) patients were treated on HITH and 103 (72%) were hospitalized. Compared with hospitalized patients, HITH patients were older (P < 0.01) and less likely to have periorbital cellulitis (P = 0.01) or fever (P = 0.04). There were no treatment failures under HITH care. The rate of antibiotic changes was similar in both groups (5% vs. 7%, P = 0.67), as was IV antibiotic duration (2.3 vs. 2.5 days, P = 0.23). CONCLUSION: Older children with moderate/severe limb cellulitis without systemic symptoms can be treated at home. To ascertain if this practice can be applied more widely, a comparative prospective, ideally randomized, study is needed.

Outcomes After Skin and Soft Tissue Infection in Infants 90 Days Old or Younger.

BACKGROUND AND OBJECTIVES: Skin and soft tissue infections (SSTIs) are an increasingly common cause of pediatric hospital visits among infants. The optimal evaluation strategy for younger infants with SSTI is unknown because there is little information about outcomes including risks of concomitant bacterial infections and treatment failure. This study was designed to determine rates of concomitant invasive bacterial infection and hospital revisits for treatment failure as well as factors associated with treatment failure in infants presenting with SSTI. METHODS: Retrospective study of patients≤90 days of age who received care from the 22 emergency departments and hospitals in the Intermountain Healthcare system from July 1, 2004 to December 31, 2011, with a primary discharge diagnosis of SSTI. Concomitant bacterial infections were defined as urinary tract infection (UTI; culture-confirmed) or invasive bacterial infection (IBI; culture-confirmed bacteremia and/or meningitis). Treatment failure was defined as any unplanned change in care at hospital revisit within 14 days of discharge. RESULTS: The study included 172 infants; 29 (17%) were febrile, and 91 (53%) had ≥1 sterile site culture performed. One case of bacteremia in a febrile infant was identified giving an overall proportion with UTI/IBI of 0.58% (95% confidence interval 0.01%-3.2%). Sixteen infants (9.3%; 95% confidence interval 5.4%-14.7%) returned for treatment failure. Perianal location (P=.03) and private insurance status (P=.01) were associated with more treatment failures compared with other locations or payer types. No patients returned for missed UTI/IBI. CONCLUSIONS: Concomitant bacterial infections were rare in infants with SSTI, with none identified in afebrile infants. Treatment failure of SSTI leading to hospital revisit was common.

Utility of Lower Extremity Doppler in Patients with Lower Extremity Cellulitis: A Need to Change the Practice?

OBJECTIVES: Cellulitis and deep vein thrombosis (DVT) in the lower extremities (LE) often have similar presentations: erythema, swelling, and calf tenderness. The overlap of these symptoms often results in physicians ordering unnecessary LE Doppler ultrasounds in patients with LE cellulitis. This practice leads to subjecting patients to unwarranted procedures and results in increased healthcare costs. We aimed to determine the percentage of Doppler ultrasounds performed in patients admitted with LE cellulitis and the prevalence of DVT in that population. METHODS: A retrospective chart review was performed of the patients admitted January 1, 2009 to June 30, 2013 who had a diagnosis of LE cellulitis. The number of Doppler ultrasounds performed and the presence of DVT was recorded. Patients were divided into groups of Doppler ultrasounds with no DVT and Doppler ultrasounds that were positive for DVT to compare the risk factors. RESULTS: There were 624 patients identified using the International Classification of Diseases, 9th Revision code for LE cellulitis at the time of admission. Slightly more than half of the subjects were men (315/624) and the average age was 61.4 ± 18.8 years (mean ± standard deviation). There were 417 (66.8%) patients who underwent Doppler ultrasound. Only 25 (5.9%) patients had DVT. Multivariate analysis showed that prior cerebrovascular accident, calf swelling, and history of thromboembolism were statistically significant predictors for DVT (P < 0.05). CONCLUSIONS: A concurrent incidence of DVT and LE cellulitis is rare. In the absence of known risk factors of DVT, the yield of LE Doppler is low and Doppler ultrasound is not required as a part of a standard admission evaluation.

Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities.

BACKGROUND AND OBJECTIVES: Older adults with ESRD often receive care in skilled nursing facilities (SNFs) after an acute hospitalization; however, little is known about acute care use after SNF discharge to home. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study used Medicare claims for North and South Carolina to identify patients with ESRD who were discharged home from a SNF between January 1, 2010 and August 31, 2011. Nursing Home Compare data were used to ascertain SNF characteristics. The primary outcome was time from SNF discharge to first acute care use (hospitalization or emergency department visit) within 30 days. Cox proportional hazards models were used to identify patient and facility characteristics associated with the outcome. RESULTS: Among 1223 patients with ESRD discharged home from a SNF after an acute hospitalization, 531 (43%) had at least one rehospitalization or emergency department visit within 30 days. The median time to first acute care use was 37 days. Characteristics associated with a shorter time to acute care use were black race (hazard ratio [HR], 1.25; 95% confidence interval [95% CI], 1.04 to 1.51), dual Medicare-Medicaid coverage (HR, 1.24; 95% CI, 1.03 to 1.50), higher Charlson comorbidity score (HR, 1.07; 95% CI, 1.01 to 1.12), number of hospitalizations during the 90 days before SNF admission (HR, 1.12; 95% CI, 1.03 to 1.22), and index hospital discharge diagnoses of cellulitis, abscess, and/or skin ulcer (HR, 2.59; 95% CI, 1.36 to 4.45). Home health use after SNF discharge was associated with a lower rate of acute care use (HR, 0.72; 95% CI, 0.59 to 0.87). There were no statistically significant associations between SNF characteristics and time to first acute care use. CONCLUSIONS: Almost one in every two older adults with ESRD discharged home after a post-acute SNF stay used acute care services within 30 days of discharge. Strategies to reduce acute care utilization in these patients are needed.

Hospital-based emergency department visits with dental conditions among children in the United States: nationwide epidemiological data.

PURPOSE: To provide nationally representative estimates of hospital-based emergency department visits (ED) for dental caries, pulp and periapical lesions, gingival/periodontal lesions, and mouth cellulitis occurring among patients who were 21 years old and younger. METHODS: Nationwide Emergency Department Sample (NEDS) for the year 2008 was used. All ED visits with dental conditions were included. Discharge patterns, demographics, disposition following ED visit, and hospital charges, were examined. NEDS is a uniform, stratified dataset, and can be projected to the national level. RESULTS: A total of 215,073 ED visits with dental conditions occurred among children. These visits included diagnosis of dental caries (50 percent of visits), pulpal and periapical conditions (41 percent), gingival (15 percent) and periodontal diseases (five percent), and mouth abscess/cellulitis (three percent). Forty-two percent were covered by Medicaid, and 32 percent were uninsured. Mean charge per visit was $564, and total ED charge across the United States (US) was $104.2 million. Among those hospitalized following ED visits, total hospitalization charge across US was $162 million. CONCLUSIONS: A substantial amount of hospital resources are spent treating dental conditions in the ED. A total of 43 percent of ED visits were covered by Medicaid, and 32 percent were uninsured.

Hospitalization for ambulatory care sensitive conditions at health insurance organization hospitals in Alexandria, Egypt.

This study aimed at estimating the percentage of hospital discharges and days of care accounted for by Ambulatory Care Sensitive Conditions (ACSCs) at Health Insurance Organization (HIO) hospitals in Alexandria, calculating hospitalization rates for ACSCs among HIO population and identifying determinants of hospitalization for those conditions. A sample of 8300 medical records of patients discharged from three hospitals affiliated to HIO at Alexandria was reviewed. The rate of monthly discharges for ACSCs was estimated on the basis of counting number of combined ACSCs detected in the three hospitals and the hospitals' average monthly discharges. ACSCs accounted for about one-fifth of hospitalizations and days of care at HIO hospitals (21.8% and 20.8%, respectively). Annual hospitalization rates for ACSCs were 152.5 per 10,000 insured population. The highest rates were attributed to cellulitis/abscess (47.3 per 10,000 population), followed by diabetes complications and asthma (42.8 and 20.8 per 10,00 population). Logistic regression indicated that age, number of previous admissions, and admission department are significant predictors for hospitalization for an ACSC.

Combined use of warfarin and oral P2Y12 inhibitors in patients with atrial fibrillation and acute coronary syndrome.

BACKGROUND: Although atrial fibrillation (AF) occurs frequently in patients hospitalized with acute coronary syndrome (ACS), strategies for prevention of thromboembolic complications are poorly characterized. HYPOTHESIS: We sought to examine exposure to warfarin and P2Y12 inhibitors and clinical outcomes among patients with AF and ACS. METHODS: Patients age >65 years hospitalized with a primary diagnosis of ACS and a secondary diagnosis of AF between 2007 and 2010 were identified in the Medicare 5% sample. Medication exposure was ascertained during a 90-day period following the index discharge using Medicare drug claims. Among patients who were alive and not readmitted during the ascertainment period, we examined the cumulative incidence of all-cause mortality and all-cause readmission by medication exposure at 1 year. RESULTS: A total of 2509 Medicare beneficiaries met the inclusion criteria. Among the 1633 patients (65%) who were alive and not readmitted during the 90-day ascertainment period, 24.0% received warfarin, 38.9% received P2Y12 inhibitors, 10.2% received combination therapy, and 26.8% received neither therapy. Readmission rates were high in all groups at 1 year (warfarin, 47.5%; P2Y12 inhibitors, 46.6%; combination therapy, 38.0%; and neither therapy, 39.3%), and the overall 1-year mortality rate was 12.5%. CONCLUSIONS: Among Medicare beneficiaries with AF and ACS, combination therapy with warfarin and P2Y12 inhibitor was uncommon during the 90-day ascertainment period, and more than one-quarter of patients had no claims for warfarin or P2Y12 inhibitors. Rates of all-cause readmission and mortality within 1 year of hospitalization for ACS were high.

The characteristics of hospital emergency department visits made by people with mental health conditions who had dental problems.

BACKGROUND: There is a paucity of knowledge regarding nationally representative estimates of hospital-based emergency department (ED) visits for dental problems made by people with mental health conditions. The authors conducted a study to provide nationwide estimates of hospital-based ED visits attributed to dental caries, pulpal and periapical lesions, gingival and periodontal lesions and mouth cellulitis/abscess made by people with mental health conditions. METHODS: The authors used the Nationwide Emergency Department Sample, which is a component of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. ED visits attributable to dental caries, pulpal and periapical lesions, gingival and periodontal lesions and mouth cellulitis/abscess were identified by the emergency care provider by using diagnostic codes in International Classification of Diseases, Ninth Revision, Clinical Modification. The authors examined outcomes, including hospital charges. They used simple descriptive statistics to summarize the data. RESULTS: In 2008, people with mental health conditions made 15,635,253 visits to hospital-based ED in the United States. A diagnosis of dental caries, pulpal and periapical lesions, gingival and periodontal lesions and mouth cellulitis/abscess represented 63,164 of these ED visits. The breakdown of the ED visits was 34,574 with dental caries, 25,352 with pulpal and periapical lesions, 9,657 with gingival and periodontal lesions, and 2,776 with mouth cellulitis/abscess. The total charge for ED visits in the United States was $55.46 million in 2008. CONCLUSIONS: In 2008, people with mental health conditions made 63,164 visits to hospital-based EDs and received a diagnosis of dental caries, pulpal and periapical lesions, gingival and periodontal lesions or mouth cellulitis/abscess. These ED visits incurred substantial hospital charges. Programs designed to reduce the number of ED visits made by this population for common dental problems could have a substantial impact in reducing the use of hospital resources. Practical Implications. Clinicians should implement preventive practices for patients with mental health conditions. The authors identified combinations of mental health conditions and dental problems that led to patients with mental health conditions making visits to hospital-based EDs for dental problems more frequently than did patients in the general population.

Socioeconomic implications of pediatric cervical methicillin-resistant Staphylococcus aureus infections.

OBJECTIVE: To study cervical methicillin-resistant Staphylococcus aureus (MRSA) infections using a national database with the goal of providing normative data and identifying variations in resource utilization. DESIGN: Retrospective review using a pediatric national data set (Kids' Inpatient Database 2009). SUBJECTS: Inclusion criteria were admissions with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for both MRSA and specific neck and pharyngeal infections. RESULTS: There were 26,829 admissions with MRSA; 3571 included a head and neck infection. The mean (SE) age at admission was 7.72 (0.20) years. Most patients (65.0%) were in the lower 2 socioeconomic quartiles; the most common payer was Medicaid (53.3%). The mean total charge per admission was $20,442. The mean (SE) length of stay (LOS) was 4.39 (0.15) days; there were significant differences among age (P < .001) and racial (P < .001) groups. A total of 1671 children underwent at least 1 surgical drainage procedure; there were statistically significant differences among racial (P < .001), age (P < .001), and socioeconomic (P = .048) groups. There were no regional variations in resource utilization when LOS, number of procedures, and total hospital charges were compared. CONCLUSIONS: Cervical MRSA infections have a large socioeconomic impact across the nation. There are differences among the various races in resource utilization. Younger children have longer hospitalizations, are more likely to need surgery, and require more intubations. Children from the lowest socioeconomic group require surgery more frequently, but their LOS is not statistically different when compared with the other 3 groups. Knowledge of such characteristics for cervical MRSA infections in children can facilitate targeted clinical interventions to improve care of affected populations.