Catastrophic Health Care Expenditure Following Brachial Plexus Injury.

PURPOSE: Brachial plexus injuries (BPIs) are devastating to patients not only functionally but also financially. Like patients experiencing other traumatic injuries and unexpected medical events, patients with BPIs are at risk of catastrophic health expenditure (CHE) in which out-of-pocket health spending exceeds 40% of postsubsistence income (income remaining after food and housing expenses). The individual financial strain after BPIs has not been previously quantified. The purpose of this study was to assess the proportion of patients with BPIs who experience risk of CHE after reconstructive surgery. METHODS: Administrative databases were used from 8 states to identify patients who underwent surgery for BPIs. Demographics including age, sex, race, and insurance payer type were obtained. Inpatient billing records were used to determine the total surgical and inpatient facility costs within 90 days after the initial surgery. Due to data constraints, further analysis was only conducted for privately-insured patients. The proportion of patients with BPIs at risk of CHE was recorded. Predictors of CHE risk were determined from a multivariable regression analysis. RESULTS: Among 681 privately-insured patients undergoing surgery for BPIs, nearly one-third (216 [32%]) were at risk of CHE. Black race and patients aged between 25 and 39 years were significant risk factors associated with CHE. Sex and the number of comorbidities were not associated with risk of CHE. CONCLUSIONS: Nearly one-third of privately-insured patients met the threshold for being at risk of CHE after BPI surgery. CLINICAL RELEVANCE: Identifying those patients at risk of CHE can inform strategies to minimize long-term financial distress after BPIs, including detailed counseling regarding anticipated health care expenditures and efforts to optimize access to appropriate insurance policies for patients with BPIs.

Association of Adverse Events With Antibiotic Treatment for Urinary Tract Infection.

BACKGROUND: Little is known about the relative harms of different antibiotic regimens prescribed to treat uncomplicated urinary tract infection (UTI). We sought to compare the risk of adverse events associated with commonly used oral antibiotic regimens for the outpatient treatment of uncomplicated UTI. METHODS: Using data from the IBM® MarketScan® Commercial Database, we identified 1 169 033 otherwise healthy, nonpregnant women aged 18-44 years with uncomplicated UTI who initiated an oral antibiotic with activity against common uropathogens from 1 July 2006 to 30 September 2015. We used propensity score-weighted Kaplan-Meier methods and Cox proportional hazards regression models to estimate the association between antibiotic agent and adverse events. RESULTS: Of 2 first-line agents, trimethoprim-sulfamethoxazole (vs nitrofurantoin) was associated with higher risk of several adverse drug events including hypersensitivity reaction (hazard ratio, 2.62; 95% confidence interval, 2.30-2.98), acute renal failure (2.56; 1.55-4.25), skin rash (2.42; 2.13-2.75), urticaria (1.37; 1.19-1.57), abdominal pain (1.14; 1.09-1.19), and nausea/vomiting (1.18; 1.10-1.28), but a similar risk of potential microbiome-related adverse events. Compared with nitrofurantoin, non-first-line agents were associated with higher risk of several adverse drug events and potential microbiome-related adverse events including non-Clostridium difficile diarrhea, C. difficile infection, vaginitis/vulvovaginal candidiasis, and pneumonia. Treatment duration modified the risk of potential microbiome-related adverse events. CONCLUSIONS: The risks of adverse drug events and potential microbiome-related events differ widely by antibiotic agent and duration. These findings underscore the utility of using real-world data to fill evidentiary gaps related to antibiotic safety.

Risk of antibiotic treatment failure in premenopausal women with uncomplicated urinary tract infection.

PURPOSE: Acute uncomplicated urinary tract infections (UTIs) are among the most common indications for antibiotic prescriptions in otherwise healthy women. We compared the risk of treatment failure of antibiotic regimens for outpatient treatment of UTI in real-world practice. METHODS: We identified non-pregnant, premenopausal women diagnosed with uncomplicated, lower tract UTI and prescribed an oral antibiotic with activity against common uropathogens. We used propensity score-weighted Kaplan-Meier functions to estimate 30-day risks and risk differences (RD) for pyelonephritis and UTI-related antibiotic prescription switch. RESULTS: Of 1 140 602 patients, the distribution of index prescriptions was 44% fluoroquinolones (non-first-line), 28% trimethoprim-sulfamethoxazole (TMP/SMX) (first-line), 24% nitrofurantoin (first-line), 3% narrow-spectrum ß-lactams (non-first-line), 1% broad-spectrum ß-lactams (non-first-line), and 1% amoxicillin/ampicillin (non-recommended). Compared to the risk of pyelonephritis for nitrofurantoin (0.3%), risks were higher for TMP/SMX (RD, 0.2%; 95% CI, 0.2%-0.2%) and broad-spectrum ß-lactams (RD, 0.2%; 95% CI, 0.1%-0.4%). Compared to the risk of prescription switch for nitrofurantoin (12.7%), the risk was higher for TMP/SMX (RD 1.6%; 95% CI 1.3%-1.7%) but similar for broad-spectrum ß-lactams (RD -0.7%; 95% CI -1.4%-0.1%) and narrow-spectrum ß-lactams (RD -0.3%; 95% CI -0.8%-0.2%). Subgroup analyses suggest TMP/SMX treatment failure may be due in part to increasing uropathogen resistance over time. CONCLUSIONS: The risk of treatment failure differed by antibiotic agent, with higher risk associated with TMP/SMX versus nitrofurantoin, and lower or similar risk associated with broad- versus narrow-spectrum ß-lactams. Given serious safety warnings for fluoroquinolones, these results suggest that nitrofurantoin may be preferable as the first-line agent for outpatient treatment of uncomplicated UTI.

Timing of Cleft Palate Repair in Patients With and Without Robin Sequence.

BACKGROUND: This cohort study aimed to assess how age at repair affects outcomes in nonsyndromic patients with and without Robin Sequence using a national database of commercial healthcare claims. METHODS: Children under 4 years of age undergoing palatoplasty were identified in the IBM MarketScan Commercial Database based on ICD-9-CM and CPT procedure codes. They were divided into Robin and non-Robin cleft palate groups, and further divided by time of initial cleft palate repair: Robin Sequence into 2 groups: age ≤10 months or >10 months; non-Robin cleft palate into 3 groups: age ≤10 months, >10-14 months, or >14 months age. Time to cleft palate revision within each group was assessed using Cox proportional-hazard models. RESULTS: A total of 261 patients with Robin Sequence and 3046 with non-Robin cleft palate were identified. In patients with Robin, later repair was associated with decreased risk of secondary procedures compared with early repair (Hazard Ratio (HR) 0.19, 95%CI 0.09-0.39, P < 0.001). In patients with non-Robin cleft palate, decreased risk of revision compared to early repair was associated both with repair at >10-14 months (adjusted HR 0.40, 95%CI 0.31-0.52, P < 0.001) and > 14 months (adjusted HR 0.71, 95%CI 0.57-0.88, P = 0.002). Adjusting for timing of repair, patients with non-Robin cleft palate were at significantly increased risk of secondary procedure if diagnosed with failure to thrive or anemia in the 30 days prior to palatoplasty. CONCLUSIONS: In patients with and without Robin sequence, cleft palate repair at or before 10 months of age was associated with higher risk for secondary procedures.

Postpartum diabetes screening among low income women with gestational diabetes in Missouri 2010-2015.

BACKGROUND: Gestational diabetes increases risk for type 2 diabetes seven-fold, creating a large public health burden in a young population. In the US, there are no large registries for tracking postpartum diabetes screening among women in under-resourced communities who face challenges with access to care after pregnancy. Existing data from Medicaid claims is limited as women often lose this coverage within months of delivery. In this study, we aim to leverage data from electronic health records and administrative claims to better assess postpartum diabetes screening rates among low income women. METHODS: A retrospective population of 1078 women with gestational diabetes who delivered between 1/1/2010 and 10/8/2015 was generated by linking electronic health record data from 21 Missouri Federally Qualified Health Centers (FQHCs) with Medicaid administrative claims. Screening rates for diabetes were calculated within 12 weeks and 1 year of delivery. Initial screening after the first postpartum year was also documented. RESULTS: Median age in the final population was 28 (IQR 24-33) years with over-representation of black non-Hispanic and urban women. In the final population, 9.7% of women had a recommended diabetes screening test within 12 weeks and 18.9% were screened within 1 year of delivery. An additional 125 women received recommended screening for the first time beyond 1 year postpartum. The percentage of women who had a postpartum visit (83.9%) and any glucose testing (40.6%) in the first year far exceeded the proportion of women with recommended screening tests. CONCLUSIONS: Linking electronic health record and administrative claims data provides a more complete picture of healthcare follow-up among low income women after gestational diabetes. While screening rates are higher than reported with claims data alone, there are opportunities to improve adherence to screening guidelines in this population.

Two-State Comparison of Total Joint Arthroplasty Utilization Following Medicaid Expansion.

BACKGROUND: Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid). METHODS: Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois' Medicaid expansion date: January 1, 2014). RESULTS: The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012). CONCLUSION: Our study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures.

The Impact of Hospital Volume on Racial Differences in Complications, Readmissions, and Emergency Department Visits Following Total Joint Arthroplasty.

BACKGROUND: Minority patients are at higher risk for complications and readmissions after total hip and knee arthroplasty. They are also more likely to undergo joint replacement in lower volume centers, which is associated with poorer outcomes. It is unknown whether these disparities simply reflect disproportionate use of lower volume centers. This study evaluates the impact of hospital volume on racial differences in outcomes following joint replacement. METHODS: Patients who underwent total hip or knee arthroplasty between 2006 and 2013 in New York and Florida were identified through the Healthcare Cost and Utilization Project State Inpatient Databases. Complications, readmissions, and emergency department (ED) visits within 90 days were compared by hospital volume. Relative risks were calculated with generalized estimating equations for risk factors associated with adverse outcomes. RESULTS: Race/ethnicity was not associated with readmission following hip replacement. Black race was associated with readmission following knee replacement (relative risk [RR] 1.16). Black race was associated with ED visits following hip replacement (RR 1.29) and knee replacement (RR 1.33). Hispanic ethnicity was associated with ED visits following knee replacement (RR 1.15), but not hip replacement. These associations did not change after adjusting for hospital volume. CONCLUSION: Adjusting for hospital volume does not alter the risk of readmissions and ED use associated with minority race/ethnicity, suggesting that hospital volume alone may be insufficient to explain racial differences in outcome.

Clostridioides difficile infection across the lifespan: Estimation using life tables.

Using a life tables approach with 2011-2017 claims data, we calculated lifetime risks of Clostridioides difficile infection (CDI) beginning at age 18 years. The lifetime CDI risk rates were 32% in female patients insured by Medicaid, 10% in commercially insured male patients, and almost 40% in females with end-stage renal disease.

Epidemiology of Intensive Care Admissions for Children in the US From 2001 to 2019.

Importance: Estimates of the number of US children receiving intensive care unit (ICU) care and ICU admission patterns over time are lacking. Objective: To determine how ICU admission patterns, use of critical care services, and the characteristics and outcomes of critically ill children have changed from 2001 to 2019. Design, Setting, and Participants: This population-based retrospective cohort study used data from the Healthcare Cost and Utilization Project's state inpatient databases from a total of 21 US states in 2001, 2004, 2010, 2016, and 2019. Hospitalized children aged 0 to 17 years, excluding newborns (during birth hospitalization), were included. Patients admitted to rehabilitation institutions or psychiatric hospitals were also excluded. Data were analyzed from July 2021 to December 2022. Exposures: Care in a nonneonatal ICU. Main Outcomes and Measures: From extracted patient data, International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision, Clinical Modification, codes were used to identify diagnoses, comorbid conditions, organ failures, and mechanical ventilation. Generalized linear Poisson regression and the Cuzick test were used to evaluate trends. US Census data were used to generate age- and sex-adjusted national estimates of ICU admissions and costs. Results: Of 2 157 991 pediatric admissions, 275 656 (12.8%) included ICU care. The mean (SD) age was 6.43 (6.10) years; 121 894 individuals were female (44.2%), and 153 731 were male (55.8%). From 2001 to 2019, the prevalence of ICU care among hospitalized children increased from 10.6% to 15.5%. The percentage of ICU admissions in children's hospitals rose from 51.2% to 85.1% (relative risk [RR], 1.66; 95% CI, 1.64-1.68). The percentage of children admitted to an ICU with an underlying comorbidity increased from 46.2% to 57.0% (RR, 1.23; 95% CI, 1.22-1.25), and the percentage with preadmission technology dependence increased from 16.4% to 23.5% (RR, 1.44; 95% CI, 1.40-1.48). The prevalence of multiple organ dysfunction syndrome increased from 6.8% to 21.0% (RR, 3.12; 95% CI, 2.98-3.26), while mortality decreased from 2.5% to 1.8% (RR, 0.72; 95% CI, 0.66-0.79). Hospital length of stay increased by 0.96 days (95% CI, 0.73-1.18) for ICU admissions from 2001 to 2019. After inflation adjustment, total costs for a pediatric admission involving ICU care nearly doubled between 2001 and 2019. Nationally, an estimated 239 000 children were admitted to a US ICU in 2019, corresponding to $11.6 billion in hospital costs. Conclusions and Relevance: In this study, the prevalence of children receiving ICU care in the US increased, as did length of stay, technology use, and associated costs. The US health care system must be equipped to care for these children in the future.

Increased Incidence and Risk of Septicemia and Urinary Tract Infection After Clostridioides difficile Infection.

Background: Although increased occurrence of septicemia in persons with Clostridioides difficile infection (CDI) has been reported, incidence rates and risk of septicemia and urinary tract infection (UTI) after CDI are unclear. Methods: The first episode of CDI was identified using 2011-2017 MarketScan and CMS Medicare data and CDI cases categorized by standard surveillance definitions. Uninfected persons were frequency matched 4:1 to cases by the CDI case surveillance definition. Multivariable Cox proportional hazards models were used to identify risk factors for septicemia and UTI within 90 days of CDI onset, accounting for the competing risk of death in the Medicare population. Results: The incidence of septicemia was highest after hospital-onset CDI in the Medicare, younger commercial, and younger Medicaid populations (25.5%, 15.7%, and 19.5%, respectively) and lowest in those with community-associated CDI (3.8%, 4.3%, and 8.3%, respectively). In contrast, the incidence of UTI was highest in those with other healthcare facility onset CDI in all 3 populations (32.1%, 24.2%, and 18.1%, respectively). Hospital-onset CDI was associated with highest risk of septicemia compared with uninfected controls in all 3 populations. In the younger populations, risk of septicemia was more uniform across the CDI surveillance definitions. The risk of UTI was significantly higher in all CDI surveillance categories compared to uninfected controls, and among CDI cases it was lowest in those with community-associated CDI. Conclusions: The incidence of septicemia is high after CDI, particularly after hospital-onset infection. Additional preventive measures are needed to reduce infectious complications of CDI.

Healthcare Costs of Clostridioides difficile Infection in Commercially Insured Younger Adults.

In a US adult population aged <65 years, attributable costs due to Clostridioides difficile infection (CDI) were highest in persons with hospital onset and lowest in those with community-associated CDI treated outside a hospital. The economic burden of CDI in younger adults underscores the need for additional CDI-preventive strategies.

Trends in the incidence of Clostridioides difficile infection in adults and the elderly insured by Medicaid compared to commercial insurance or Medicare only.

OBJECTIVE: Few data are available to quantify the Clostridioides difficile infection (CDI) burden in US adults depending on Medicaid insurance status; thus, we sought to contribute to this body of information. METHODS: Retrospective cohort study to identify adults with codes for CDI from 2011 to 2017 in MarketScan commercial and Medicaid databases (for those aged 25-64 years) and the CMS Medicare database (for those aged ≥65 years). CDI was categorized as healthcare-facility-associated (HCA-CDI) and community-associated CDI (CA-CDI). CDI incidence rates were compared by year, insurer, and age group. RESULTS: The overall CDI incidence in the elderly was 3.1-fold higher in persons insured by Medicare plus Medicaid than in those insured by Medicare only (1,935 vs 618 per 100,000 person years (PY)), and the CDI incidence was 2.7-fold higher in younger adults with Medicaid compared to commercial insurance (195 vs 73 per 100,000 PY). From 2011 to 2017, HCA-CDI rates declined in the younger Medicaid population (124.0 to 95.2 per 100,000 PY; P < .001) but were stable in those commercially insured (25.9 to 24.8 per 100,000 PY; P = .33). In the elderly HCA-CDI rates declined from 2011 to 2017 in the Medicare-only population (403 to 318 per 100,000 PY; P < .001) and the Medicare plus Medicaid population (1,770 to 1,163 per 100,000 PY; P < .002). Persons with chronic medical conditions and those with immunocompromising conditions insured by Medicaid had 2.8- and 2.7-fold higher CDI incidence compared to the commercially insured population, respectively. The incidence of CDI was lowest in Medicaid and commercially insured younger adults without chronic medical or immunosuppressive conditions (67.5 and 45.6 per 100,000 PY, respectively). CONCLUSIONS: Although HCA-CDI incidence decreased from 2011 to 2017 in elderly and younger adults insured by Medicaid, the burden of CDI remains much higher in low-income adults insured by Medicaid.

Factors Associated With Postpartum Diabetes Screening in Women With Gestational Diabetes and Medicaid During Pregnancy.

INTRODUCTION: Women with gestational diabetes are 7 times more likely to develop type 2 diabetes and require lifelong diabetes screening. Loss of health coverage after pregnancy, as occurs in states that did not expand Medicaid, limits access to guideline-driven follow-up care and fosters health inequity. This study aims to understand the factors associated with the receipt of postpartum diabetes screening for women with gestational diabetes in a state without Medicaid expansion. METHODS: Electronic health record and Medicaid claims data were linked to generate a retrospective cohort of 1,078 women with gestational diabetes receiving care in Federally Qualified Health Centers in Missouri from 2010 to 2015. In 2019-2020, data were analyzed to determine the factors associated with the receipt of recommended postpartum diabetes screening (fasting plasma glucose, 2-hour oral glucose tolerance test, or HbA1c in specified timeframes) using a Cox proportional hazards model through 18 months of follow-up. RESULTS: Median age in this predominantly urban population was 28 (IQR=24-33) years. Self-reported racial or ethnic minorities comprised more than half of the population. Only 9.7% of women were screened at 12 weeks, and 20.8% were screened at 18 months. Prenatal certified diabetes education (adjusted hazard ratio=1.74, 95% CI=1.22, 2.49) and access to public transportation (adjusted hazard ratio=1.70, 95% CI=1.13, 2.54) were associated with increased screening in a model adjusted for race/ethnicity, the total number of prenatal visits, the use of diabetes medication during pregnancy, and a pregnancy-specific comorbidity index that incorporated age. CONCLUSIONS: This study underscores the importance of access to public transportation, prenatal diabetes education, and continued healthcare coverage for women on Medicaid to support the receipt of guideline-recommended follow-up care and improve health equity.

Care Fragmentation and Mortality in Readmission after Surgery for Hepatopancreatobiliary and Gastric Cancer: A Patient-Level and Hospital-Level Analysis of the Healthcare Cost and Utilization Project Administrative Database.

BACKGROUND: Hepatopancreatobiliary (HPB) and gastric oncologic operations are frequently performed at referral centers. Postoperatively, many patients experience care fragmentation, including readmission to "outside hospitals" (OSH), which is associated with increased mortality. Little is known about patient-level and hospital-level variables associated with this mortality difference. STUDY DESIGN: Patients undergoing HPB or gastric oncologic surgery were identified from select states within the Healthcare Cost and Utilization Project database (2006-2014). Follow-up was 90 days after discharge. Analyses used Kruskal-Wallis test, Youden index, and multilevel modeling at the hospital level. RESULTS: There were 7,536 patients readmitted within 90 days of HPB or gastric oncologic surgery to 636 hospitals; 28% of readmissions (n = 2,123) were to an OSH, where 90-day readmission mortality was significantly higher: 8.0% vs 5.4% (p < 0.01). Patients readmitted to an OSH lived farther from the index surgical hospital (median 24 miles vs 10 miles; p < 0.01) and were readmitted later (median 25 days after discharge vs 12; p < 0.01). These variables were not associated with readmission mortality. Surgical complications managed at an OSH were associated with greater readmission mortality: 8.4% vs 5.7% (p < 0.01). Hospitals with <100 annual HPB and gastric operations for benign or malignant indications had higher readmission mortality (6.4% vs 4.7%, p = 0.01), although this was not significant after risk-adjustment (p = 0.226). CONCLUSIONS: For readmissions after HPB and gastric oncologic surgery, travel distance and timing are major determinants of care fragmentation. However, these variables are not associated with mortality, nor is annual hospital surgical volume after risk-adjustment. This information could be used to determine safe sites of care for readmissions after HPB and gastric surgery. Further analysis is needed to explore the relationship between complications, the site of care, and readmission mortality.

The Risks of Stone Diagnosis and Stone Removal Procedure After Different Bariatric Surgeries.

Introduction: Nephrolithiasis is common after malabsorptive bariatric surgery; however, the comparative risk of stone formation after different bariatric surgeries remains unclear. We seek to compare the risk of stone diagnosis and stone procedure after gastric banding (GB), sleeve gastrectomy (SG), short-limb Roux-en-Y (SLRY), long-limb Roux-en-Y (LLRY), and biliopancreatic diversion with duodenal switch (BPDDS). Patients and Methods: Using an administrative database, we retrospectively identified 116,304 patients in the United States, who received bariatric surgery between 2007 and 2014, did not have a known kidney stone diagnosis before surgery, and were enrolled in the database for at least 1 year before and after their bariatric surgery. We used diagnosis and procedural codes to identify comorbidities and events of interest. Our primary analysis was performed with extended Cox proportional hazards models using time to stone diagnosis and time to stone procedure as outcomes. Results: The adjusted hazard ratio of new stone diagnosis from 1 to 36 months, compared to GB, was 4.54 for BPDDS (95% confidence interval [CI] 3.66-5.62), 2.12 for LLRY (95% CI 1.74-2.58), 2.15 for SLRY (95% CI 2.02-2.29), and 1.35 for SG (95% CI 1.25-1.46). Similar results were observed for risk of stone diagnosis from 36 to 60 months, and for risk of stone removal procedure. Male sex was associated with an overall 1.63-fold increased risk of new stone diagnosis (95% CI 1.55-1.72). Conclusions: BPDDS was associated with a greater risk of stone diagnosis and stone procedures than SLRY and LLRY, which were associated with a greater risk than restrictive procedures. Nephrolithiasis is more common after more malabsorptive bariatric surgeries, with a much greater risk observed after BPDDS and for male patients.

Potential missed opportunities for diagnosis of cryptococcosis and the association with mortality: A cohort study.

BACKGROUND: Cryptococcosis is one of the most common life-threatening opportunistic mycoses worldwide. Insidious presentation and slow onset of symptoms make it difficult to recognize, complicating the diagnostic process. Delays in diagnosis may lead to increased mortality. We aim to determine the frequency of missed opportunities for diagnosis of cryptococcosis and its effects on mortality. METHODS: To estimate the proportion of individuals with a potentially missed diagnosis for cryptococcosis in hospitalized patients, we conducted a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient Databases from 2005 to 2015 from eight states. All hospitalized adult patients diagnosed with cryptococcal infection or cryptococcal meningitis were included. Potentially missed diagnoses were defined as admissions coded for a procedure or diagnosis suggestive of cryptococcosis in the 90-days prior to the initial cryptococcosis admission. Generalized estimating equations models were used to evaluate the association between underlying comorbidities and potential missed diagnosis of cryptococcosis and 90-day all-cause in-hospital mortality. FINDINGS: Of 5,354 patients with cryptococcosis, 2,445 (45·7%) were people living with HIV (PLWH). Among PLWH, 493/2,445 (20·2%) had a potentially missed diagnosis, of which 83/493 (16·8%) died while hospitalized compared with 265/1,952 (13·6%) of those without a potentially missed diagnosis (relative risk [RR] 1·04, 95% CI 0·99-1·09). Among HIV-negative patients, 977/2,909 (33·6%) had a potentially missed diagnosis, of which 236/977 (24·2%) died while hospitalized compared with 298/1,932 (15·4%) of those not missed (RR 1·12, 95% CI 1·07-1·16). INTERPRETATION: Missed opportunities to diagnose cryptococcosis are common despite highly efficacious diagnostic tests and are associated with increased risk of 90-day mortality in HIV-negative patients. A high index of clinical suspicion is paramount to promptly diagnose, treat, and improve cryptococcosis-related mortality. FUNDING: National Center for Advancing Translational Sciences, Washington University Institute of Clinical and Translational Sciences, and the Agency for Healthcare Research and Quality.

Simplified risk prediction indices do not accurately predict 30-day death or readmission after discharge following colorectal surgery.

BACKGROUND: Risk-prediction indices are one category of the many tools implemented to guide efforts to decrease readmissions. However, using fied models to predict a complex process can prove challenging. In addition, no risk-prediction index has been developed for patients undergoing colorectal surgery. Therefore, we evaluated the performance of a widely utilized simplified index developed at the hospital level - LACE (length of stay, acute admission, Charlson comorbidity index score, and emergency department visits) and developed and evaluated a novel index in predicting readmissions in this patient population. METHODS: Using a retrospective split-sample cohort, patients discharged after colorectal surgery were identified within the inpatient databases of the Healthcare Cost and Utilization Project for the states of New York, California, and Florida (2006-2014). The primary outcome was death or readmission within 30 days after discharge. Multivariable logistic regression models incorporated patient comorbidities, postoperative complications, and hospitalization details, and were evaluated using the C statistic. RESULTS: A total of 440,742 patients met eligibility criteria. The rate of death or readmission within 30 days after discharge was 14.0% (n = 61,757). When applied to surgical patients, the LACE index demonstrated a poor model fit (C = 0.631). The model fit improved significantly-but remained poor (C = 0.654; P < .001)-with the addition of the following variables, which are known to be associated with readmission after colorectal surgery: age, indication for surgery, and creation of a new ostomy. A novel, simplified model also yielded a poor model fit (C = 0.660). CONCLUSION: Postdischarge death or readmission after colorectal surgery is not accurately modeled using existing, modified, or novel simplified risk prediction models. Payers and providers must ensure that quality improvement efforts applying simplified models to complex processes, such as readmissions following colorectal surgery, may not be appropriate, and that models reflect the relevant patient population.