Hospitalization as an opportunity to improve lung cancer screening in high-risk patients.

BACKGROUND: Lung cancer screening with annual low-dose computed tomography (LDCT) in high-risk patients with exposure to smoking reduces lung cancer-related mortality, yet the screening rate of eligible adults is low. As hospitalization is an opportune moment to engage patients in their overall health, it may be an opportunity to improve rates of lung cancer screening. Prior to implementing a hospital-based lung cancer screening referral program, this study assesses the association between hospitalization and completion of lung cancer screening. METHODS: A retrospective cohort study of evaluated completion of at least one LDCT from 2014 to 2021 using electronic health record data using hospitalization as the primary exposure. Patients aged 55-80 who received care from a university-based internal medicine clinic and reported cigarette use were included. Univariate analysis and logistic regression evaluated the association of hospitalization and completion of LDCT. Cox proportional hazard model examined the time relationship between hospitalization and LDCT. RESULTS: Of the 1935 current smokers identified, 47% had at least one hospitalization, and 21% completed a LDCT during the study period. While a higher proportion of patients with a hospitalization had a LDCT (24%) compared to patients without a hospitalization (18%, p<0.001), there was no association between hospitalization and completion of a LDCT after adjusting for potentially confounding covariates (95%CI 0.680 - 1.149). There was an association between hospitalization time to event and LDCT completion, with hospitalized patients having a lower probability of competing LDCT compared to non-hospitalized patients (HR 0.747; 95% CI 0.611 - 0.914). CONCLUSIONS: In a cohort of patients at risk for lung cancer and established within a primary care clinic, only 1 in 4 patients who had been hospitalized completed lung cancer screening with LDCT. Hospitalization events were associated with a lower probability of LDCT completion. Hospitalization is a missed opportunity to refer at-risk patients to lung cancer screening.

Effect of Delirium on Interhospital Transfer Outcomes.

OBJECTIVES: Interhospital transfer (IHT) and in-hospital delirium are both independently associated with increased length of stay (LOS), mortality, and discharge to facility. Our objective was to investigate the joint effects between IHT and the presence of in-hospital delirium on the outcomes of LOS, discharge to a facility, and in-hospital mortality. METHODS: This was a single-center retrospective cohort study of 25,886 adult hospital admissions at a tertiary-care academic medical center. Staged multivariable logistic and linear regression models were used to evaluate the association between IHT status and the outcomes of discharge to a facility, LOS, and mortality while considering the joint impact of delirium. The joint effects of IHT status and delirium were evaluated by categorizing patients into one of four categories: emergency department (ED) admissions without delirium, ED admissions with delirium, IHT admissions without delirium, and IHT admissions with delirium. The primary outcomes were LOS, in-hospital mortality, and discharge disposition. RESULTS: The odds of discharge to a facility were 4.48 times higher in admissions through IHT with delirium when compared with ED admissions without delirium. IHT admissions with delirium had a 1.97-fold (95% confidence interval 1.88-2.06) longer LOS when compared with admission through the ED without delirium. Finally, admissions through IHT with delirium had 3.60 (95% confidence interval 2.36-5.49) times the odds of mortality when compared with admissions through the ED without delirium. CONCLUSIONS: The relationship between IHT and delirium is complex, and patients with IHT combined with in-hospital delirium are at high risk of longer LOS, discharge to a facility, and mortality.

Is hospitalization a missed opportunity to intervene on tobacco cessation?

BACKGROUND: Although tobacco use is associated with elevated morbidity and mortality, its use remains widespread among adults within the United States. Nicotine Replacement Therapy (NRT) products are effective aids that improve rates of tobacco cessation. Many smokers interact with the medical system, such as during hospitalization, without their tobacco use addressed. Hospitalization is a teachable moment for patients to make health-related changes, including tobacco cessation. METHODS: Retrospective cohort study of adult patients in a university-based patient-centered medical home from 2012 to 2021 evaluating the proportion of adults who smoke who received at least one prescription for NRT. Logistic regression models were used to analyze the association of being hospitalized and receipt of a NRT prescription. RESULTS: Of the 4,072 current smokers identified, 1,182 (29%) received at least one prescription for NRT during the study period. Hospitalization was associated with increased odds of receiving a NRT prescription (OR 1.68). Of 1,844 current smokers with a hospitalization during the study period, 1,078 (58%) never received a prescription for NRT at any point. Only 87 (5%) of the smokers received a prescription for NRT during hospitalization or at the time of hospital discharge. CONCLUSIONS: Despite hospitalization being associated with NRT prescribing, most patients who use tobacco and are hospitalized are not prescribed NRT. Hospitalization is an underutilized opportunity for both hospitalists and primary care physicians to intervene on smoking cessation through education and prescription of tobacco cessation aids.

Development and Assessment of Simulation-Based Point-of-Care Ultrasound Curriculum in Undergraduate Medical Education.

OBJECTIVES: Implementation barriers and lack of standardized point-of-care ultrasound (POCUS) curricula make the development of effective POCUS curricula and methods of assessment challenging. The authors aim to develop a longitudinal POCUS curriculum through staged intervention. In the first stage, the authors hypothesized that the use of high-fidelity ultrasound simulation during the Internal Medicine clerkship would improve POCUS confidence and knowledge among medical students, minimizing the need for trained faculty. METHODS: A quasi-experimental study of third-year students on the Internal Medicine clerkship at a large academic medical center in the United States was performed assessing the efficacy of ultrasound simulation use. The control group consisted of students who received baseline POCUS education during teaching rounds but did not have access to the ultrasound simulator. The experimental group consisted of students who, in addition to baseline POCUS education, had access to a high-fidelity ultrasound simulator throughout the clerkship for a minimum of 1 hour per week. Students in both the control and experimental groups completed a pre- and post-intervention confidence survey and knowledge-based examination. RESULTS: Eighty-two percent (50/61) of students completed pre- and post-tests, with the control group demonstrating no significant difference in POCUS confidence or knowledge. After exposure to the ultrasound simulator, the experimental group demonstrated statistically significant improvement in POCUS confidence and overall POCUS knowledge (p < .01). CONCLUSION: The use of high-fidelity ultrasound simulation can improve POCUS confidence and knowledge among medical students while addressing common barriers to the implementation of a POCUS curriculum. Despite showing statistically significant improvement in overall knowledge, the results did not appear to hold educational significance. Additional POCUS educational methods are necessary to overcome cognitive bias and potential overconfidence. The next stage of curriculum development will include resident-led POCUS workshops to supplement simulation.

The Combined Effect of Delirium and Falls on Length of Stay and Discharge.

INTRODUCTION: Delirium or a fall are associated with many negative outcomes including increased length of stay (LOS) and discharge to a facility; however, this relationship is incompletely understood. METHODS: A cross-sectional study of all hospitalizations in a large, tertiary care hospital evaluated the effect of delirium and a fall on the outcomes of LOS and risk of being discharged to a facility. RESULTS: The study included 29,655 hospital admissions. A total of 3,707 (12.5%) patients screened positive for delirium and 286 (0.96%) had a reported fall. After adjustment for covariates, relative to patients without delirium or a fall, patients with delirium only had a 1.64-fold longer LOS; patients with fall only had a 1.96-fold longer LOS; and patients who had delirium and fall had a 2.84-fold longer LOS. The adjusted odds of discharge to a facility, relative to those without delirium or a fall, was 8.98 times higher in those with delirium and a fall. CONCLUSIONS: Delirium and falls influence LOS and likelihood of being discharged to a facility. The joint impact of falls and delirium on LOS and facility discharge was more than additive. Hospitals should consider the integrated management of delirium and falls.

The Association between Delirium and In-Hospital Falls: A Cross-Sectional Analysis of a Delirium Screening Program.

Methods: A cross-sectional study using delirium screening and falls reports was used to measure the association between delirium and falls. All inpatient data from August, 2018, to January, 2020, at a large academic medical center were analyzed. A multivariable logistic regression of 29,655 hospital admissions was used to understand the association between in-hospital delirium and falls. Results: Analysis revealed a delirium rate of 12.5% (n = 3,707) of all admissions and 286 (0.9%) admissions with falls; of the falls studied, 37.6% of these patients screened positive for delirium during their admission. Relative to those who screened negative for delirium, admissions that screened positive for delirium had a 2.81 increased odds of falling. Conclusions: Delirium and falls are related. This strong association should motivate health systems to look closely at both problems. Falls and delirium can both have immense impacts on the patient and the health system. The powerful association between them provides a window to reduce these additional patient harms. More specifically, a modern delirium screening tool should be used as part of routine risk assessment focused on reducing in-hospital falls.

Understanding the association between admission source and in-hospital delirium: A cross-sectional study.

Patients admitted via interhospital transfer (IHT) experience increased risk-adjusted mortality, adverse events, length of stay, and discharge to facility; however, the etiology is not well understood. We hypothesize that IHTs are more likely to experience in-hospital delirium as compared with admissions to the hospital via the emergency department (ED) and clinic. This is a cross-sectional study of all adult admissions to medical, surgical, neurological, and obstetrics and gynecology services at an academic medical center who were screened for delirium between August 2018 and January 2020. Unit of analysis was admission source (IHT vs ED vs clinic) as the independent variable and the primary outcome was in-hospital delirium, assessed with initial brief confusion assessment method (bCAM) screening. 30,100 hospitalizations were included in this study with 3925 admissions (13.0%) screening positive for delirium at the initial bCAM assessment. The prevalence of delirium was much higher in IHTs at 22.3% (1334/5971) when compared with clinic at 5.8% (244/4214) and ED at 11.8% (2347/19,915) admissions. Multivariable logistic regression adjusting for demographics and comorbidities showed that IHT admissions had higher odds (OR 1.91, 95% CI 1.74 to 2.10) and clinic admissions had lower odds (OR 0.56, 95% CI 0.48 to 0.64) of in-hospital delirium compared with ED admissions. Increased odds of delirium in IHT admissions may contribute to the observed increased length of stay, discharge to facility, and mortality. These results emphasize the importance of routine screening and possible intervention prior to patient transfer.

Use of point-of-care ultrasound by internists to rapidly diagnose acute decompensated heart failure.

Dyspnea is a common presenting complaint seen by hospitalists. The differential is broad, including life-threatening and less urgent etiologies. We report a 43-year-old male presenting to an inpatient medicine service with dyspnea in the setting of asthma, tobacco and occupational exposures, and no prior cardiac history. Use of point-of-care ultrasound (POCUS) immediately confirmed diagnosis of acute decompensated heart failure, allowing prompt decision making and care. Use of POCUS is widespread among emergency physicians and intensivists; however, use among medical students, internal medicine residents, and hospitalists remains variable. Increased use of POCUS by hospitalists may increase speed and accuracy of diagnosis.

The Impact of Internal Medicine Clerkship Characteristics and NBME Subject Exams on USMLE Step 2 Clinical Knowledge Exam Performance.

BACKGROUND: Residency program directors will likely emphasize the United States Medical Licensing Exam (USMLE) Step 2 clinical knowledge (CK) exam more during residency application given the recent USMLE Step 1 transition to pass/fail scoring. We examined how internal medicine clerkship characteristics and NBME subject exam scores affect USMLE Step 2 CK performance. DESIGN: The authors used univariable and multivariable generalized estimating equations to determine associations between Step 2 CK performance and internal medicine clerkship characteristics and NBME subject exams. The sample had 21,280 examinees' first Step 2 CK scores for analysis. RESULTS: On multivariable analysis, Step 1 performance (standardized ß = 0.45, p < .001) and NBME medicine subject exam performance (standardized ß = 0.40, p < .001) accounted for approximately 60% of the variance in Step 2 CK performance. Students who completed the internal medicine clerkship last in the academic year scored lower on Step 2 CK (Mdiff = -3.17 p < .001). Students who had a criterion score for passing the NBME medicine subject exam scored higher on Step 2 CK (Mdiff = 1.10, p = .03). There was no association between Step 2 CK performance and other internal medicine clerkship characteristics (all p > 0.05) nor with the total NBME subject exams completed (ß=0.05, p = .78). CONCLUSION: Despite similarities between NBME subject exams and Step 2 CK, the authors did not identify improved Step 2 CK performance for students who had more NBME subject exams. The lack of association of Step 2 CK performance with many internal medicine clerkship characteristics and more NBME subject exams has implications for future clerkship structure and summative assessment. The improved Step 2 CK performance in students that completed their internal medicine clerkship earlier warrants further study given the anticipated increase in emphasis on Step 2 CK.

Ascitic Fluid Analysis Leading to the Diagnosis of Constrictive Pericarditis in 2 Patients.

Although well documented, constrictive pericarditis is a rare entity and an uncommon cause of heart failure. A stiff and noncompliant pericardium creates the disease's unique hemodynamics and leads to elevated venous pressures, hepatic sinusoidal congestion, and draining of protein-rich fluid into the peritoneal cavity presenting as ascites. The low incidence in addition to its varied and subtle clinical presentations can often lead to a delay in diagnosis. Here, we present 2 clinical cases of constrictive pericarditis in which ascitic fluid analysis was important-one patient who presented with new-onset ascites with concern for cirrhosis and another patient who presented with symptoms concerning for heart failure with ascites. Through their hospital course and workup, we highlight the importance of diagnostic sampling of ascitic fluid to prompt the consideration of constrictive pericarditis followed by utilizing advanced diagnostics, such as echocardiogram and cardiac catheterization to reach the correct diagnosis in an otherwise often overlooked pathology.

Disseminated Nontuberculous Mycobacterium Presenting as Chronic Diarrhea and Wasting.

Infections due to nontuberculous mycobacterium (NTM) are important in chronically immunosuppressed populations and are a particular threat to solid organ transplant recipients (SOT). However, they are not a common occurrence and have protean manifestations, making it important that clinicians maintain a high degree of suspicion in the correct patient population. Mycobacterium avium complex (MAC) usually presents with pulmonary involvement in immunocompetent population and disseminated disease in SOT patients with fever of unknown origin, lymphadenopathy, and cutaneous lesions being part of the well-known presentation. It is not commonly described as causing severe diarrhea. Here, we present an interesting case of a patient with a kidney and pancreas transplant who presented with debilitating wasting and chronic diarrhea. Biopsies and cultures confirmed MAC. To our knowledge, this is the first case report of MAC causing severe wasting diarrhea in renal transplant patients. The patient was treated with a multidrug regimen. Given the rare presentation of MAC presenting as chronic diarrhea, the treatment regimen is not standardized and infectious disease specialists should be involved early on. Up to 30% of renal transplant patients infected with NTM lose graft function and 20% die. Unfortunately, our patient suffered both these outcomes.

Pyometra: An Atypical Cause of Abdominal Pain.

Pyometra, a purulent infection of the uterus, is a rare cause of a very common complaint-abdominal pain. Risk factors include gynecologic malignancy and postmenopausal status. The classically described presentation includes abdominal pain, fever, and vaginal discharge. In this article, we present an atypical presentation of nonperforated pyometra in an 80-year-old female who was admitted to the internal medicine inpatient service. She initially presented with nonspecific subacute right lower quadrant abdominal pain. Physical examination did not demonstrate vaginal discharge. Laboratory evaluation failed to identify an underlying etiology. Computed tomography scan of the abdomen and pelvis with oral and intravenous contrast demonstrated a 6.5 × 6.1 cm cystic containing structure within the uterine fundus, concerning for a gynecologic malignancy. Pelvis ultrasound confirmed the mass. Endometrial biopsy did not reveal underlying malignancy, but instead showed frank pus, leading to the diagnosis of pyometra. This report illustrates that pyometra should be considered in the differential diagnosis of lower abdominal pain in elderly women.

Patient Demographics and Clinic Type Are Associated With Patient Engagement Within a Remote Monitoring Program.

Background: Remote physiological monitoring (RPM) is accessible, convenient, relatively inexpensive, and can improve clinical outcomes. Yet, it is unclear in which clinical setting or target population RPM is maximally effective. Objective: To determine whether patients' demographic characteristics or clinical settings are associated with data transmission and engagement. Methods: This is a prospective cohort study of adults enrolled in a diabetes RPM program for a minimum of 12 months as of April 2020. We developed a multivariable logistic regression model for engagement with age, gender, race, income, and primary care clinic type as variables and a second model to include first-order interactions for all demographic variables by time. The participants included 549 adults (mean age 53 years, 63% female, 54% Black, and 75% very low income) with baseline hemoglobin A1c ≥8.0% and enrolled in a statewide diabetes RPM program. The main measure was the transmission engagement over time, where engagement is defined as a minimum of three distinct days per week in which remote data are transmitted. Results: Significant predictors of transmission engagement included increasing age, academic clinic type, higher annual household income, and shorter time-in-program (p < 0.001 for each). Self-identified race and gender were not significantly associated with transmission engagement (p = 0.729 and 0.237, respectively). Conclusions: RPM appears to be an accessible tool for minority racial groups and for the aging population, yet engagement is impacted by primary care location setting and socioeconomic status. These results should inform implementation of future RPM studies, guide advocacy efforts, and highlight the need to focus efforts on maintaining engagement over time.

Estimating the Economic Burden of Acute Myocardial Infarction in the US: 12 Year National Data.

BACKGROUND: Acute myocardial infarction (AMI) carries a substantial mortality and morbidity burden. The purpose of this study is to provide annual mean cost per patient and national level estimates of direct and indirect costs (lost productivity from morbidity and premature mortality) associated with AMI. METHODS: Nationally representative data spanning 12 years (2003-2014) with a sample of 324,869 patients with AMI from the Medical Expenditure Panel Survey (MEPS) were analyzed. A novel 2-part model was used to examine the excess direct cost associated with AMI, controlling for covariates. To estimate lost productivity from morbidity, an adjusted Generalized Linear Model was used for the differential in wage earnings between participants with and without AMI. Lost productivity from premature mortality was estimated based on published data. RESULTS: The total annual cost of AMI in 2016 dollars was estimated to be $84.9 billion, including $29.8 billion in excess direct medical expenditures, $14.6 billion in lost productivity from morbidity and $40.5 billion in lost productivity from premature mortality between 2003 and 2014. In the adjusted regression, the overall excess direct medical expenditure of AMI was $7,076 (95% confidence interval [CI] $6,028-$8,125) higher than those without AMI. After adjustment, annual wages for patients with AMI were $10,166 (95% CI -$12,985 to -$7,347) lower and annual missed work days were 5.9 days (95% CI 3.57-8.27) higher than those without AMI. CONCLUSIONS: The study finds that the economic burden of AMI is substantial, for which effective prevention could result in significant health and productivity cost savings.

Impact of Patient-Level Characteristics on In-hospital Mortality After Interhospital Transfer to Medicine Services: an Observational Study.

BACKGROUND: National administrative datasets have demonstrated increased risk-adjusted mortality among patients undergoing interhospital transfer (IHT) compared to patients admitted through the emergency department (ED). OBJECTIVE: To investigate the impact of patient-level data not available in larger administrative datasets on the association between IHT status and in-hospital mortality. DESIGN: Retrospective cohort study with logistic regression analyses to examine the association between IHT status and in-hospital mortality, controlling for covariates that were potential confounders. Model 1: IHT status, admit service. Model 2: model 1 and patient demographics. Model 3: model 2 and disease-specific conditions. Model 4: model 3 and vital signs and laboratory data. PARTICIPANTS: Nine thousand three hundred twenty-eight adults admitted to Medicine services. MAIN MEASURES: Interhospital transfer status, coded as an unordered categorical variable (IHT vs ED vs clinic), was the independent variable. The primary outcome was in-hospital mortality. Secondary outcomes included unadjusted length of stay and total cost. KEY RESULTS: IHT patients accounted for 180 out of 484 (37%) in-hospital deaths, despite accounting for only 17% of total admissions. Unadjusted mean length of stay was 8.4 days vs 5.6 days (p < 0.0001) and mean total cost was $22,647 vs $12,968 (p < 0.0001) for patients admitted via IHT vs ED respectively. The odds ratios (OR) for in-hospital mortality for patients admitted via IHT compared to the ED were as follows: model 1 OR, 2.06 (95% CI 1.66-2.56, p < 0.0001); model 2 OR, 2.07 (95% CI 1.66-2.58, p < 0.0001); model 3 OR, 2.07 (95% CI 1.63-2.61, p < 0.0001); model 4 OR, 1.70 (95% CI 1.31-2.19, p < 0.0001). The AUCs of the models were as follows: model 1, 0.74; model 2, 0.76; model 3, 0.83; model 4, 0.88, consistent with a good prediction model. CONCLUSIONS: Patient-level characteristics affect the association between IHT and in-hospital mortality. After adjusting for patient-level clinical characteristics, IHT status remains associated with in-hospital mortality.

When Do Clinicians Follow-up Abnormal Liver Tests in Primary Care?

BACKGROUND: Many guidelines addressing the approach to abnormal liver chemistries, including bilirubin, transaminases and alkaline phosphatase, recommend repeating the tests. However, when clinicians repeat testing is unknown. MATERIAL AND METHODS: This retrospective study followed adult patients with abnormal liver chemistries in a patient-centered medical home (PCMH) from 2007 to 2016. All PCMH patients possessing at least 1 abnormal liver test (total bilirubin, aminotransferases and alkaline phosphatase) were included. Patients were followed from the index abnormal liver chemistry until the next liver test result, or the end of the study period. The primary predictor variable of interest was the number of abnormal chemistries (out of 4) on index testing. Demographic and clinical variables served as other potential predictors of outcome. A Cox proportional hazards model was applied to investigate associations between the predictor variables and the time to repeat liver chemistry testing. RESULTS: Of 9,545 patients with at least 2 PCMH visits and 1 liver test abnormality, 6,489 (68%) obtained repeat testing within 1 year, and 80% of patients had follow-up tests within 2 years. Patients with multiple abnormal liver tests and those with higher degrees of abnormality were associated with shorter time to repeat testing. CONCLUSIONS: A large proportion of patients with abnormal liver tests still lack repeat testing at 1 year. The number of liver abnormal liver tests and degree of elevation were inversely associated with the time to repeat testing.

Porphyria Cutanea Tarda Associated With Acute Hemorrhagic Pancreatitis.

Porphyria cutanea tarda (PCT) is a condition of dysregulated heme synthesis that leads to accumulation of photosensitizing precursors with resultant fragility and blistering of the skin. It can be hereditary or acquired and has been known to be associated with hepatic C virus, alcohol, HIV, and estrogen. In this article, we report an unusual presentation of PCT associated with acute hemorrhagic pancreatitis in a 57-year-old man. He presented initially to a community hospital with acute onset of epigastric abdominal pain and new-onset ascites. Lipase was elevated. Diagnostic paracentesis was grossly bloody. He was then transferred to our institution for concern for acute hemorrhagic pancreatitis. On arrival, physical examination demonstrated vesicles and bullae with erythematous bases, in different stages of healing seen over the dorsal aspects of both hands with scaling, scarring, and hypopigmentation and hyperpigmentation of the skin. Laboratory evaluation and skin biopsy confirmed the diagnosis of PCT. Search for an underlying etiology failed to reveal typical predisposing factors. This report illustrates that acute hemorrhagic pancreatitis may be an underlying etiology for PCT.

Patient perception of obesity versus physician documentation of obesity: A quality improvement study.

As the prevalence of obesity increases, the prevalence of associated comorbid diseases, obesity-related mortality rates and healthcare costs rise concordantly. Two main factors that hinder efforts to treat obesity include a lack of recognition by patients and documentation by physicians. This study evaluates the relationship between patient perception of obese weight and physician documentation of obesity. This quality improvement observational study surveyed patients of an academic internal medicine clinic on their perception of obesity. Responses were compared to longitudinal physician documentation of obesity and body mass index (BMI). A total of 59.9% of patients with obesity perceived their weight as obese. While 33.7% of patients with a BMI of 30 to 34.9 kg/m2 perceived themselves as having obesity, 71.4% of patients with a BMI of 45 to 49.9 kg/m2 perceived themselves as having obesity. A total of 42.4% of patients with obesity had physician documentation of obesity in the last year. While 25% of patients with a BMI of 30 to 34.9 kg/m2 had physician documentation of obesity, 85.7% of patients with a BMI of 45 to 49.9 kg/m2 had physician documentation of obesity. For patients with a BMI ≥50 kg/m2 , 52.9% perceived their weight to be obese and 76.5% had physician documentation of obesity in the last year. Both patient perception and physician documentation of obesity were significantly less than the prevalence of obesity. Patient perception of obesity and provider documentation of obesity increased as BMI increased until a BMI ≥50 kg/m2 . Both patients and providers must improve recognition of this disease.

Trends in Healthcare Expenditures Among US Adults With Hypertension: National Estimates, 2003-2014.

BACKGROUND: One in 3 US adults has high blood pressure, or hypertension. As prior projections suggest hypertension is the costliest of all cardiovascular diseases, it is important to define the current state of healthcare expenditures related to hypertension. METHODS AND RESULTS: We used a nationally representative database, the Medical Expenditure Panel Survey, to calculate the estimated annual healthcare expenditure for patients with hypertension and to measure trends in expenditure longitudinally over a 12-year period. A 2-part model was used to estimate adjusted incremental expenditures for individuals with hypertension versus those without hypertension. Sex, race/ethnicity, education, insurance status, census region, income, marital status, Charlson Comorbidity Index, and year category were included as covariates. The 2003-2014 pooled data include a total sample of 224 920 adults, of whom 36.9% had hypertension. Unadjusted mean annual medical expenditure attributable to patients with hypertension was $9089. Relative to individuals without hypertension, individuals with hypertension had $1920 higher annual adjusted incremental expenditure, 2.5 times the inpatient cost, almost double the outpatient cost, and nearly triple the prescription medication expenditure. Based on the prevalence of hypertension in the United States, the estimated adjusted annual incremental cost is $131 billion per year higher for the hypertensive adult population compared with the nonhypertensive population. CONCLUSIONS: Individuals with hypertension are estimated to face nearly $2000 higher annual healthcare expenditure compared with their nonhypertensive peers. This trend has been relatively stable over 12 years. Healthcare costs associated with hypertension account for about $131 billion. This warrants intense effort toward hypertension prevention and management.