Rural-Urban Differences in In-Hospital Mortality Among Admissions for End-Stage Liver Disease in the United States.

Access to quality hospital care is a persistent problem for rural patients. Little is known about disparities between rural and urban populations regarding in-hospital outcomes for end-stage liver disease (ESLD) patients. We aimed to determine whether rural ESLD patients experienced higher in-hospital mortality than urban patients and whether disparities were attributable to the rurality of the patient or the center. This was a retrospective study of patient admissions in the National Inpatient Sample, a population-based sample of hospitals in the United States. Admissions were included if they were from adult patients who had an ESLD-related admission defined by codes from the International Classification of Diseases, Ninth Revision, between January 2012 and December 2014. The primary exposures of interest were patient-level rurality and hospital-level rurality. The main outcome was in-hospital mortality. We stratified our analysis by disease severity score. After accounting for patient- and hospital-level covariates, ESLD admissions to rural hospitals in every category of disease severity had significantly higher odds of in-hospital mortality than patient admissions to urban hospitals. Those with moderate or major risk of dying had more than twice the odds of in-hospital mortality (odds ratio [OR] for moderate risk, 2.41; 95% confidence interval [CI], 1.62-3.59; OR for major risk, 2.49; 95% CI, 1.97-3.14). There was no association between patient-level rurality and mortality in the adjusted models. In conclusion, ESLD patients admitted to rural hospitals had increased odds of in-hospital mortality compared with those admitted to urban hospitals, and the differences were not attributable to patient-level rurality. Our results suggest that interventions to improve outcomes in this population should focus on the level of the health system.

Venous thromboembolism in cancer patients undergoing major surgery.

BACKGROUND: Cancer patients undergoing major abdominal or pelvic surgery are at considerable risk of venous thromboembolism (VTE). The genesis of thromboses in malignancy is complicated, and reflects the interaction and derangement of multiple molecular pathways. Furthermore, the nature and location of the cancer, as well as the type surgery involved, are thought to affect the level of VTE risk. These considerations may therefore affect treatment decisions. METHODS: We performed multiple Medline searches with terms including but not limited to VTE, cancer, surgery, abdominal, colorectal, unfractionated heparin (UFH), and low-molecular-weight heparin (LMWH) to identify reviews, meta-analyses, nonrandomized and randomized controlled trials, and clinical guidelines relating to management of VTE in patients with abdominal cancer. RESULTS: VTE incidence in patients with malignancy varied according to cancer type, location, stage of progression, and the use of catheters and/or chemotherapy. Thromboprophylaxis with UFH or LMWH reduces the risk of developing VTE in these patients. However, LMWHs have a favorable risk-benefit profile over UFH and extending the duration prophylaxis may improve outcomes. CONCLUSION: A number of recommendations can be made for the prevention of VTE in patients undergoing abdominal or pelvic surgery for cancer: (1) risk-stratify all patients according to defined evidence-based guidelines; (2) for most abdominal surgical oncology patients at risk, use of both an anticoagulant and mechanical means are indicated and beneficial; and (3) consider extended-duration prophylaxis (up to 28 days) in those patients with major abdominal/pelvic operations and impaired mobility, preferably with LMWH.