Congenital Heart Defects and Concurrent Diagnoses in Influenza Hospitalization in the Pediatric Health Information System Study, 2004-2019.

Influenza is associated with adverse outcomes in children, although modification by additional medical conditions is not well-documented. We aimed to compare outcomes in children with versus without congenital heart defects (CHDs) who were hospitalized for influenza. We retrospectively evaluated patients 1-18y hospitalized for influenza in the Pediatric Health Information (PHIS) database from 2004 to 2019. Outcomes were compared by CHD presence and then by CHD severity (minor biventricular, major biventricular, and single ventricle disease) using log-binomial regression adjusted for propensity scores accounting for age at admission, sex, and history of asthma. Outcomes included inpatient mortality, intensive care unit (ICU) admission, mechanical ventilation, and length of stay (LOS) > 12 days. To evaluate for effect modification by genetic diagnoses, analyses were repeated stratified by CHD and genetic diagnosis. Among 55,161 children hospitalized for influenza, 2369 (4.3%) had CHDs, including 963 with minor biventricular, 938 with major biventricular, and 468 with single ventricle CHDs. Adjusting for propensity scores, children with CHDs had higher mortality (4.1% versus 0.9%) compared to those without CHDs (risk ratio [RR] 2.5, 95% confidence interval [CI] 1.9-3.4). Children with CHDs were at higher risk of mechanical ventilation (RR 1.6, 95% CI 1.6-1.7), ICU admission (RR 1.9, 95% CI 1.8-2.1), and LOS > 12 days (RR 2.2, 95% CI 2.0-2.3). Compared to those with neither CHD nor genetic condition, children with both had significantly higher risk of all outcomes, with the largest difference for LOS > 12 days (RR 2.3, 95% CI 2.0-2.7). Children with CHDs hospitalized for influenza are particularly susceptible to adverse outcomes compared to those without CHDs. Future studies are needed to corroborate findings in light of influenza vaccination.

Impact of cesarean versus vaginal delivery on the risk of postpartum acute kidney injury: A retrospective database controlled study in 116,876 parturients.

STUDY OBJECTIVE: The rate of cesarean delivery is increasing globally but the risk of perioperative organ injury associated with cesarean delivery is not well defined. The objective of this study was to determine the risk of postpartum acute kidney injury, a peripartum complication defined by an acute decrease in kidney function, associated with cesarean delivery compared to vaginal delivery. SETTING: Population-based discharge database. PATIENTS: The Optum Clinformatics® Data Mart was queried for parturients that underwent cesarean or vaginal delivery between January 2016 to January 2018. Using a propensity score model based on 27 antepartum characteristics, we generated a final matched cohort of 116,876 parturients. INTERVENTION/EXPOSURE: Cesarean delivery as the mode of delivery. MEASUREMENTS: The risk of acute kidney injury associated with each delivery mode and the effect of acute kidney injury on the length of hospital stay for parturients. MAIN RESULTS: The matched cohort consisted of 116,876 deliveries, with 58,438 cases in each group. In the cesarean delivery group, the incidence of postpartum acute kidney injury was 24.5 vs. 7.9 per 10,000 deliveries in the vaginal delivery group (adjusted odds ratio = 3; 95% CI, 2.13-4.22; P < .001). The median of the length of hospital stay [interquartile range] was longer by 50% in parturients who developed postpartum acute kidney injury after vaginal delivery (3 [2-4] days vs. those who did not, 2 [2, 3] days; P < .001) and by 67% after cesarean delivery (5 [4-7] days vs. 3 [3, 4] days; P < .001). CONCLUSIONS: Cesarean delivery is associated with a significantly increased risk of postpartum acute kidney injury as compared to vaginal delivery. The development of postpartum acute kidney injury is associated with prolonged length of hospital stay.

Is Post-discharge Rehabilitation Timing Associated with 90-Day Readmission in Primary Total Joint Arthroplasty?

BACKGROUND: Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications that lead to readmission. However, evidence-based guidelines about appropriate post-discharge rehabilitative care are not well-defined in the orthopedic literature. PURPOSES: We sought to determine the average timing for receiving PT rehabilitation and to evaluate the association between PT rehabilitation timing and unplanned readmission within 90 days of a TJA patient being discharged home from acute care. METHODS: This retrospective study examined 11,545 joint procedures using claims data for the years 2008 to 2013. Outcomes were assessed using a population-averaged approach to regression models. RESULTS: The average time for initiating PT was 4 days for knee arthroplasty and 6 days for hip arthroplasty in patients discharged home from acute care. Most patients (89%) began PT consultation or supervised exercises during the first week after discharge. The type of joint surgery considerably modified the effect of rehabilitation timing on the likelihood of readmission. Later initiation of rehabilitation was associated with a higher probability of 90-day readmission in both knee and hip arthroplasty, with the effect of rehabilitation timing being more pronounced in hip rather than knee arthroplasty 2 weeks post-discharge from acute care. CONCLUSIONS: Timing for initiating PT may be an important modifiable factor that can affect readmission in patients discharged home from acute care after TJA. Further exploration of the role of PT timing along with other factors such as dosage and frequency among such patients is needed.

What Factors are Associated With 90-day Episode-of-care Payments for Younger Patients With Total Joint Arthroplasty?

BACKGROUND: Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most studies in this area have focused primarily on the Medicare population and rarely have characterized the younger commercially insured populations. Understanding the inpatient and postdischarge care service-component differences across 90-day episodes of care and factors associated with payments for younger patients is crucial for successful implementation of bundled payments in TJA in non-Medicare populations. PURPOSE: (1) To assess the mean total payment for a 90-day primary TJA episode, including the proportion attributable to postdischarge care, and (2) to evaluate the role of procedure, patient, and hospital-level factors associated with 90-day episode-of-care payments in a non-Medicare patient population younger than 65 years. METHOD: Claims data for 2008 to 2013 from Blue Cross Blue Shield of Texas were obtained for primary TJAs. A total of 11,131 procedures were examined by aggregating payments for the index hospital stay and any postacute care including rehabilitation services and unplanned readmissions during the 90-day postdischarge followup period. A three-level hierarchical model was developed to determine procedure-, patient-, and hospital-level factors associated with 90-day episode-of-care payments. RESULTS: The mean total payment for a 90-day episode for TJA was USD 47,700 adjusted to 2013 USD. Only 14% of 90-day episode payments in our population was attributable to postdischarge-care services, which is substantially lower than the percentage estimated in the Medicare population. A prolonged length of stay (rate ratio [RR], 1.19; 95% CI, 1.15-1.23; p ≤ 0.001), any 90-day unplanned readmission (RR, 1.64; 95% CI, 1.57-1.71; p ≤ 0.001), computer-assisted surgery (RR, 1.031; 95% CI, 1.004-1.059; p ≤ 0.05), initial home discharge with home health component (RR, 1.029; 95% CI, 1.013-1.046; p ≤ 0.001), and very high patient morbidity burden (RR, 1.105; 95% CI, 1.062-1.150; p ≤ 0.001) were associated with increased TJA payments. Hospital-level factors associated with higher payments included urban location (RR, 1.29; 95% CI, 1.17-1.42; p ≤ 0.001), lower hospital case mix based on average relative diagnosis related group weight (RR, 0.94; 95% CI, 0.89-0.95; p ≤ 0.001), and large hospital size as defined by total discharge volume (RR, 1.082; 95% CI, 1.009-1.161; p ≤ 0.05). All procedure, patient, and hospital characterizing factors together explained 11% of variation among hospitals and 49% of variation among patients. CONCLUSION: Inpatient care contributed to a much larger proportion of total payments for 90-day care episodes for primary TJA in our younger than 65-year-old commercially insured population. Thus, inpatient care will continue to be an essential target for cost-containment and delivery strategies. A high percentage of hospital-level variation in episode payments remained unexplained by hospital characteristics in our study, suggesting system inefficiencies that could be suitable for bundling. However, replication of this study among other commercial payers in other parts of the country will allow for conclusions that are more robust and generalizable. LEVEL OF EVIDENCE: Level II, economic analysis.

Prevalence of in-hospital nonsteroidal antiinflammatory drug exposure in patients with a primary diagnosis of heart failure.

AIM: To determine the prevalence of in-hospital nonsteroidal antiinflammatory drug (NSAID) exposure and associated outcomes in patients admitted with a primary diagnosis of heart failure. METHODS: We performed a propensity-matched cohort analysis of patients admitted to Houston Methodist Hospital System with a primary diagnosis of heart failure according to the International Classification of Diseases-9-Clinical Modification (ICD-9-CM) from January 1, 2011 to December 31, 2014. RESULTS: Of the 9742 patients admitted with a primary diagnosis of heart failure, 384 patients (3.9%) were exposed to NSAID. After applying propensity scores we matched 305 NSAID exposed with 915 unexposed patients. Patients with in-hospital NSAID exposure had a longer length of stay (7.0±8.8 days vs 6.1±8.5; P=.003) and increased prevalence of worsening renal function (34.4% vs 27.9%; P=.030). There were not statically significant differences in in-hospital mortality rate or 30-day all-cause readmission rate. CONCLUSION: Exposure to NSAID in patients admitted with a primary diagnosis of heart failure was low but was associated with adverse outcomes including longer length of stay and higher prevalence or worsening renal function.

Fine particulate matter components and emergency department visits among a privately insured population in Greater Houston.

Although adverse health effects of PM2.5 (particulate matter with aerodynamic diameter less than 2.5µm) mass have been extensively studied, it remains unclear regarding which PM2.5 components are most harmful. No studies have reported the associations between PM2.5 components and adverse health effects among a privately insured population. In our study, we estimated the short-term associations between exposure to PM2.5 components and emergency department (ED) visits for all-cause and cause-specific diseases in Greater Houston, Texas, during 2008-2013 using ED visit data extracted from a private insurance company (Blue Cross Blue Shield Texas [BCBSTX]). A total of 526,453 ED visits were included in our assessment, with an average of 236 (±63) visits per day. We selected 20 PM2.5 components from the U.S. Environmental Protection Agency's Chemical Speciation Network site located in Houston, and then applied Poisson regression models to assess the previously mentioned associations. Interquartile range increases in bromine (0.003µg/m(3)), potassium (0.048µg/m(3)), sodium ion (0.306µg/m(3)), and sulfate (1.648µg/m(3)) were statistically significantly associated with the increased risks in total ED of 0.71% (95% confidence interval (CI): 0.06, 1.37%), 0.71% (95% CI: 0.21, 1.22%), 1.28% (95% CI: 0.34, 2.24%), and 1.22% (95% CI: 0.23, 2.23%), respectively. Seasonal analysis suggested strongest associations occurred during the warm season. Our findings suggest that a privately insured population, presumably healthier than the general population, may be still at risk of adverse health effects due to exposure to ambient PM2.5 components.

In-hospital use of non-steroidal anti-inflammatory drugs in patients with heart failure in academic centers in the United States.

BACKGROUND: Non-steroidal anti-inflammatory drugs are considered potentially harmful for patients with heart failure. OBJECTIVE: To determine the prevalence of in-hospital NSAID use, their type, associated diagnosis and impact in clinical outcomes among patients with a diagnosis of heart failure. METHODS: The University Health System Consortium Database was used to identify all first hospitalizations with an International Classification of Diseases-9 discharge diagnosis code of systolic heart failure as the primary diagnosis between January 1, 2011, and December 31st 2014. RESULTS: Among 65,902 patients admitted for a primary diagnosis of SHF, 2675 (4.1%) were exposed to NSAID. The most frequent NSAID used was ibuprofen (51.63%), followed by ketorolac (29.38%) naproxen (8.07%) celecoxib (5.61%), and others. On multivariable analyses, the length of stay of patients exposed to NSAID was longer compared to non-exposed (OR: 4.67, p < 0.001, 95% CI 4.10-5.25), but differences in mortality were not statistically different (OR: 0.90, p = 0.476, 95% CI 0.69-1.19). CONCLUSION: The use of NSAID in patients admitted with a primary diagnosis of systolic heart failure was low but was associated with longer length of stay. Further studies are needed to understand the impact of NSAID use in this patient population.

Effect of Public Reporting on MR Imaging Use for Low Back Pain.

PURPOSE: To determine whether magnetic resonance (MR) imaging examination rates for low back pain before conservative therapy in the Medicare and privately insured populations changed after introduction of a Centers for Medicare & Medicaid Services public reporting initiative. MATERIALS AND METHODS: Institutional review board approval was obtained, with waiver of informed consent. A retrospective study was performed by using fee-for-service claims data from Medicare and a commercial carrier (Blue Cross Blue Shield of Texas [BCBSTX]) for Texas enrollees. OP-8 was calculated, which is a publicly reported measure as of 2009 of the proportion of MR imaging examinations performed for low back pain without history of conservative therapy. For 330 463 MR imaging examinations, OP-8 rates, trends, and regional variation were analyzed for 2008-2011 within different outpatient settings-outpatient hospital department (OHD) and nonhospital outpatient department (NOD)-according to payer. Largest-volume hospitals were also evaluated within the Medicare population. RESULTS: No significant reduction was found in annual OP-8 values for Medicare or BCBSTX (Medicare OHD, 0.35 for 2008 vs 0.36 for 2009 [P = .01]; BCBSTX OHD, 0.42 for 2008 vs 0.44 for 2009 [P = .03]; Medicare NOD, 0.33 for 2008 vs 0.35 for 2009 [P < .0001]; and BCBSTX NOD, 0.43 for 2008 vs 0.42 for 2009[P = .23]). These changes were not sustained during subsequent years in the BCBSTX population, and there were no further changes in Medicare rates. Among hospitals with highest Medicare volumes, those with the highest OP-8 rates in 2008 were associated with the highest decrease in their measure. (The annual change rate was negative for all years, with 2008 as the reference [P < .0001 for 2009-2011].) Hospitals with the lowest OP-8 rates had increases in OP-8 rates, which persisted in following years (P = .006 for 2009, P = .037 for 2010, and P = .004 for 2011). Hospitals with baseline OP-8 rates in the 25th-75th percentile remained relatively steady over time. CONCLUSION: No evidence was found that public reporting (OP-8) reduced MR imaging rates for low back pain without conservative therapy in either Medicare or commercially insured populations in hospital or nonhospital settings.

[Health reform in the USA]. / La reforma del sistema de salud de los Estados Unidos de América.

The United States of America passed early this year the bill enforcing their health reform. this reform aims at achieving universal insurance, cost containment and improving quality of care. The debate around this reform has been long and unable to arrive to an agreement between the parts. Even if the expansion in the medical coverage system does not reduce to zero the current degree of inaccessibility to the health system, these achievements could be considered a very important first step. Nonetheless, chances are that this reform will continue being as polemic as the negotiations previous to its conception.

Epidemiological study of influenza virus infections in young adult outpatients from Buenos Aires, Argentina.

BACKGROUND: Influenza virus is the most common cause of influenza-like illness (ILI) in adults. In Argentina, studies on influenza and other respiratory viruses were performed mostly in pediatric populations. OBJECTIVES: To determine: (1) the frequency of influenza virus and other common respiratory viruses in adult outpatients with ILI, (2) whether the signs and symptoms predict viral etiology, (3) whether viral diagnosis changes clinical management or infection control measures and (4) to characterize the influenza strains circulating in the community. POPULATION AND METHODS: Nasal and pharyngeal swabs from adult outpatients with ILI attending the emergency room during the winter seasons of 2004 and 2005 in Argentina were evaluated by immunofluorescence and RT-PCR. RESULTS: Of 151 samples analyzed, 39 (26%) were influenza A positive, 5 (3.3%) influenza B positive and 4 (2.6%) respiratory syncytial virus positive by immunofluorescence. Two samples (1.3%) were human metapneumovirus positive by RT PCR. Cell culture detected six additional influenza viruses and one adenovirus positive sample. The sensitivity of immunofluorescence for influenza compared with culture was 70%. Symptoms did not predict etiology. CONCLUSIONS: In this study, 40% of the patients with ILI had a specific viral infection and 83% were influenza viruses. Viral detection was necessary to determine the etiology as signs and symptoms were not different between patients with or without viral infection. Viral diagnosis was important to implement infectious control measures. Circulating influenza strains in this study were similar to the correspondent vaccine strains selected for the Southern hemisphere.