Hidden Dangers of Frailty: Higher Mortality, Complications and Costs in Acute Pancreatitis.

BACKGROUND: Frailty is a clinically recognizable state of increased vulnerability due to age-related decline in reserve and function across multiple physiologic systems that compromises the ability to cope with acute stress. As frailty is being identified as an important risk factor in outcomes of gastrointestinal pathologies, we aimed to assess outcomes in patients with acute pancreatitis within this cohort. METHOD: We conducted a retrospective study using the Nationwide Inpatient Sample (NIS) database. ICD-10 codes were used to inquire for patients admitted with acute pancreatitis between September 2015 through 2017. ICD-10 codes corresponding to the Hospital Frailty Risk Score (HFRS) were used to divide the study sample into 2 cohorts: low risk (< 5 points) and intermediate or high risk (> 5 points). To calculate the points, we fitted a logistic regression model that included membership of the frail group as the binary dependent variable (frail vs. non-frail) and the set of ICD-10 codes as binary predictor variables (1 = present, 0 = absent for each code). To simplify the calculation and interpretation, we multiplied regression coefficients by five to create a points system, so that a certain number of points are awarded for each ICD-10 code and added together to create the final frailty risk score. Multivariate regression analysis was performed to find adjusted mortality. RESULTS: Out of a total of 1,267,744 patients admitted with acute pancreatitis, 728,953 (57.5%) were identified as intermediate and high risk (> 5 points) (study cohort) and 538,781 (42.5%) as low risk (< 5 points). The mean age in the study cohort was 64.8 ± 12.6 and that in the low-risk group was 58.6 ± 9.5. Most of the patients in both groups were males and Caucasians; Medicare was the predominant insurance provider. A majority of the admissions in both groups were in an urban teaching hospital and were emergency. (Table 1). The primary outcome was in-hospital mortality which was significantly higher in the study cohort as compared to the low-risk group (4.3% vs. 2.5%, p < 0.0001). The age-adjusted Odds ratio of mortality was 1.72(95% CI (Confidence Interval) 1.65-1.80, p < 0.05). When compared between the two groups; median length of stay (6 vs. 4); hospitalization cost ($14,412 vs. $10,193), disposition to a skilled nursing facility (SNF) (17.1% vs. 8.6%) and need for home health care (HHC) was significantly higher in the study cohort. Complications like septicemia, septic shock, and acute kidney injury were also higher in the study group (Table 2). Table 1 Baseline demographics of the cohort Characteristics Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value N = 1,267,744 N = 728,953 (57.5%) N = 538,781 (42.5%) Age  Mean years (Mean ± SD) 64.8 ± 12.6 58.6 ± 9.5 < 0.001 Gender < 0.001  Male 59.1% 52.3%  Female 40.9% 47.7% *Missing-475 Age groups < 0.001  18-44 3.7% 14.3%  45-64 48% 52.9%  65-84 32.2% 28.7%  ≥ 85 16.1% 4.1% Race < 0.001  Caucasians 67.4% 61.9%  African Americans 9.6% 16.8%  Others 23% 21.3% *Missing-10 Insurance type < 0.001  Medicare 40.9% 36.3%  Medicaid 17.2% 24.3%  Private 31.8% 27.9%  Other 9.9% 11.4% *Missing-75 Active smoking 32.7% 37.9% 0.005 Biliary Stone 36.2% 16.7% < 0.001 Admission Type < 0.001  Emergent 93.7% 94.3%  Elective 6.3% 5.7% *Missing-2880 Hospital ownership/control < 0.001  Rural 7.8% 10%  Urban nonteaching 26.3% 26.6%  Urban teaching 65.9% 63.4% Table 2 Outcomes Outcomes Acute pancreatitis with High HES Frailty score (> 5, intermediate + high) Acute pancreatitis with low HES Frailty score (< 5) P-value In-hospital mortality *Missing-920 4.3% 2.5% < .0001 1.72(1.65-1.80) < .0001 Length of stay, days (Median,IQR) 6(3-8) 4(2-6) < .0001 Total hospitalization cost, $ (Median,IQR) 14,412(8843-20,216) 10,193(6840-13,842) < .0001 In-Hospital Complications  ARDS 0.4% 0.3% 0.08  Ventilator dependence respiratory failure 0.23% 0.29% 0.25  Septicemia 15.2% 9.6% < .0001  Septic Shock 6.1% 2.9% < .0001  AKI 24.8% 14.9% < .0001 Disposition < .0001  Discharge to home 58.9% 74.9%  Transfer other: includes  Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), and another type of facility 17.1% 8.6%  Home health care 11.5% 8.1%  Against medical advice (AMA) 1.6% 3.4% *Missing-920 CONCLUSION: Using frailty as a construct to identify those who are at greater risk for adverse outcomes, can help formulate interventions to target individualized reversible factors to improve outcomes in patients with acute pancreatitis. Future large-scale prospective studies are warranted to understand the dynamic and longitudinal relationship between pancreatitis and frailty.

P065 A One-Time Education for Gastroenterologists Regarding Osteoporosis Screening for IBD Patients Improves Provider Knowledge But Not Screening Rates.

BACKGROUND: Inflammatory Bowel Disease (IBD) is a chronic gastrointestinal inflammatory condition and has been increasing in prevalence in the United States, with a 30-40% increase over the past few decades. Osteoporosis can be seen in up to 40% of IBD patients. Screening for osteoporosis in IBD patients involves the use of DEXA scans and is recommended by the IBD Cornerstone Committee for select patients, including steroid use > 3 months consecutively or a total of 1 year in the past 2 years, family history of osteoporosis, malnutrition, amenorrheic or post-menopausal. Our quality improvement study looked to improve osteoporosis screening among gastroenterologists. METHODS: We conducted a retrospective chart review on all IBD patients within the St. Luke's Network and extrapolated data on age (>50 in male and >65 in female), sex, chronic glucocorticoid use (3 month consecutively or cumulative), osteoporosis/osteopenia diagnosis, vitamin D (vit-D) levels, and DEXA scan between 2019 to 2021. We gave a 5-minute presentation on current DEXA screen recommendations for patients with IBD on 5/27/2021 to all the network's gastroenterologists, which totaled 12. We performed a pre and post education survey consisting of 5 questions on provider knowledge and comfortability with osteoporosis screening. We assessed provider knowledge, as well as rates of osteoporosis screening. All statistical analyses were conducted in IBM SPSS for Windows Version 26. Chi Square tests were used to compare two groups in categorical variables while Mann-Whitney tests were done to compare continuous variables like age and vit-D levels. RESULTS: There were a total of 5442 patients; 3927 patients before the educational intervention on 5/27/2021 and 1515 patients after the intervention. Both pre and post intervention groups were balanced in terms of age, gender, smoking status, and alcohol risk. Percent of DEXA scans were similar between both groups (13.0% vs 12.3%, p=0.5). DEXA screening rates among patients with chronic steroid use pre-intervention vs post-intervention was 44.45 vs 42.4% respectively. Vit-D levels compared between both groups was not statistically significant (30.5 vs 31.8, p=0.1). Surveys conducted before and after the intervention showed an overall increase in percentage of agreement responses about knowledge and confidence in DEXA screening (88.5% vs 97.5%). CONCLUSION: DEXA scanning can help detect premature decrease in bone mineral density and provide physicians with the opportunity to prevent further morbidity. Our study showed no difference in DEXA screening rates before and after intervention. However, there was an increase in provider knowledge based on post-intervention surveys. A similar study showed that it took three interventions, including educational presentation, flyers, and on screen EMR reminders for there to be a sustainable improvement in the rate of DEXA screening. Our project may have required additional interventions to produce an effect and thus reinforces the need for further efforts to improve osteoporosis screening in IBD patients.

A Retrospective Cohort Study From the National Inpatient Sample Database (2016-2019): Does Obesity Affect the Outcomes of Hospitalization Due to Hepatocellular Carcinoma?

INTRODUCTION: Obesity is commonly reported to be associated with hepatocellular carcinoma (HCC) along with higher risks of mortality. However, there is a significant research gap regarding the outcomes of hospitalization due to HCC among obese patients compared to those without obesity. This study compares the outcomes of hospitalization among those two groups. METHODS:  A total of 50,845 patients admitted from 2016 to 2019 with a principal admission diagnosis of HCC were identified using the International Classification of Disease 10 (ICD-10) coding from the National Inpatient Sample (NIS) database. Patients with a body mass index (BMI) >30 were stratified into the obese cohort, and those with BMI ≤30 into the non-obese cohort as per the ICD-10 coding criteria for obesity based on BMI. The primary outcome of the study was mortality, whereas the length of stay, total hospitalization charges, acute kidney injury (AKI), sepsis, and shock were the secondary outcomes. We also compared additional complications such as ascites, portal hypertension, acute liver failure, disseminated intravascular coagulation (DIC), hepatic encephalopathy, and hepatorenal syndrome between the two groups. A multivariate regression model was used to estimate the effect of obesity on outcomes of hospitalization due to HCC. RESULTS: The obese cohort comprised 10.64% of the study population, whereas the non-obese cohort comprised 89.36% of the study population. Compared to the non-obese cohort, the obese cohort of patients with HCC were more likely to have a higher comorbidity index (CCI ≥4: 79.76% in the obese vs 71.17 % in the non-obese cohort). Obesity was found to be a protective factor for in-hospital mortality; that is, the odds of in-hospital mortality among the obese cohort was 0.713 times than that of the non-obese group of patients with HCC. The obese cohort had a higher mean length of stay (6.3 days vs 5.6 days; p value: <0.001) and total hospitalization charges (109,108$ vs 85,406$; p value: <0.001), which was further validated on multivariate analysis. The obese cohort had 1.26 times odds of developing AKI compared to the non-obese cohort (p value: 0.005). Sepsis, shock, and other complications such as acute liver failure, DIC, hepatic encephalopathy, hepatorenal syndrome, and portal hypertension were not significantly different between the two groups. CONCLUSION:  Obesity was associated with reduced in-hospital mortality among patients with HCC. However, obese patients with HCC were found to have higher healthcare resource utilization in terms of length of stay and total hospitalization charge along with the development of AKI. Clinicians should be mindful of the potential longer length of stay and associated complications such as AKI while managing obese patients with HCC. Contrary to commonly held notions, obesity and its relation with in-hospital mortality reported in this study warrants further explorative research.

Jaundice on Presentation Is Associated with Higher In-Patient Mortality and Complications in Patients Admitted for Acute Pancreatitis: A Retrospective Study Based on National Inpatient Sample Database.

Pancreatitis usually presents with characteristic abdominal pain, radiological findings, and elevated lipase. The presence of jaundice may hint at a biliary etiology; however, it is not always present. We hypothesized that the presence of jaundice is associated with worse outcomes in patients admitted with pancreatitis. We conducted a retrospective analysis using the National Inpatient Sample, inquiring about patients admitted with pancreatitis with and without jaundice between October 2015 and December 2017. The primary outcome was in-hospital mortality in patients admitted for pancreatitis with and without jaundice. Secondary outcomes were the median length of stay, hospitalization cost, the incidence of ventilator-dependent respiratory failure (VDRF), acute respiratory distress syndrome (ARDS), sepsis, septic shock, dehydration and electrolyte disturbances, and ascites. A total of 1,267,744 patients were admitted with pancreatitis from October 2015 to December 2017. Among them, 8855 (0.7%) had concomitant jaundice on presentation. In-hospital mortality in this group was 4.3%. The patients with pancreatitis and jaundice had higher odds of in-hospital mortality (adjusted odds ratio [aOR]: 1.51, 99% CI 1.35-1.68, p < 0.0001) as compared to those without jaundice. Patients with jaundice showed a significantly higher incidence of sepsis (15.2% vs. 9.6%, p < 0.0001), septic shock (4.1% vs. 2.9%, p < 0.0001), ascites (6.5% vs. 3.1%, p < 0.0001), and dehydration and electrolyte disorders (47.6% vs. 43.8%, p < 0.0001). Patients with jaundice also had higher total hospital costs ($11,412 vs. $7893, p < 0.0001). There was no statistical difference in ARDS, VDRF, and median length of stay. In conclusion, patients admitted for pancreatitis with jaundice had worse outcomes, including in-hospital mortality and complications, compared to those without jaundice.