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Li R, Sarin S. Evaluating outcomes of transjugular intrahepatic portosystemic shunt procedure among Native Americans. Am J Med Sci 2025; 369:145-151. [PMID: 39154964 DOI: 10.1016/j.amjms.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 08/09/2024] [Accepted: 08/12/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND This study aims to explore racial disparities in immediate outcomes of Transjugular Intrahepatic Portosystemic Shunt (TIPS) among Native Americans, a group that have higher prevalence of liver cirrhosis but were the "invisible group" in previous TIPS studies due to their small population size. METHODS The study identified Native Americans and Caucasians who underwent TIPS in National/Nationwide Inpatient Sample (NIS) database from Q4 2015-2020. Preoperative factors, including demographics, indications for TIPS, comorbidities, etiologies for liver disease, primary payer status, and hospital characteristics, were matched by 1:5 propensity score matching. In-hospital post-TIPS outcomes were then compared between the two cohorts. RESULTS There were 6,658 patients who underwent TIPS, where 101 (1.52%) were Native Americans and 4,574 (68.70%) were Caucasians. Native Americans presented as younger, with a lower socioeconomic status, and displayed higher rates of alcohol abuse and related liver diseases. After propensity-score matching, Native Americans had comparable in-hospital post-TIPS outcomes including mortality (8.33% vs 9.09%, p = 1.00), hepatic encephalopathy (18.75% vs 25.84%, p = 0.19), acute kidney injury (28.13% vs 30.62%, p = 0.71), and other adverse events. Native Americans also had similar wait from admission to operation (2.15 ± 0.30 vs 2.87 ± 0.21 days, p = 0.13), hospital length of stay (7.43 ± 0.63 vs 8.62 ± 0.47 days, p = 0.13), and total costs (158,299 ± 14,218.2 vs 169,425 ± 8,600.7 dollars, p = 0.50). CONCLUSION Native Americans had similar immediate outcomes after TIPS compared to their propensity-matched Caucasians. While these results underscore effective healthcare delivery of TIPS to Native Americans, it is imperative to pursue further research for long-term post-procedure outcomes.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Shawn Sarin
- The George Washington University Hospital, Department of Interventional Radiology, Washington, DC, USA
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Wang YZ, Xue C, Ma C, Liu AB. Associations of the Charlson comorbidity index with depression and mortality among the U.S. adults. Front Public Health 2024; 12:1404270. [PMID: 39664531 PMCID: PMC11632622 DOI: 10.3389/fpubh.2024.1404270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 10/18/2024] [Indexed: 12/13/2024] Open
Abstract
BACKGROUND Chronic comorbidities are often associated with higher risks of depression and mortality. This study aims to explore the relationships between the Charlson Comorbidity Index (CCI) and depression, and their combined effect on mortality. METHODS This study made use of data gathered in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018, including a collective of 23,927 adult participants. According to CCI score distribution, CCI was categorized into three groups (T1 with CCI = 0; T2 with CCI = 1; T3 with CCI ≥ 2). In the CCI ≥ 2 group, patients may have two or more chronic diseases. Multivariable logistic regression models were employed to explore the relationship between CCI and depression. The study utilized the Cox proportional hazards model to investigate the association between CCI, the combination of CCI and depression, and all-cause mortality. RESULTS Our analysis revealed that after adjusting for potential confounders, a positive association was found between CCI and depression (OR = 1.25, 95% CI: 1.21, 1.29). Moreover, a greater CCI was found to be closely linked to higher mortality in individuals with depression (HR = 1.14, 95% CI 1.11, 1.18). Stratifying CCI into tertiles, higher tertiles of CCI (T2, T3 vs T1) also showed positive associations with depression and all-cause mortality. For patients with CCI ≥2 (T3) combined with depression, the risk of mortality was significantly elevated compared to those with CCI = 0 (T1) and non-depressed participants (HR = 2.01, 95% CI: 1.60, 2.52). CONCLUSION The study findings demonstrate a positive correlation between CCI and the risk of depression, along with an association with increased all-cause mortality among depression patients. Hence, it is important to prioritize the clinical care of patients with a high CCI (≥2) and depression in order to lower the chances of mortality.
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Affiliation(s)
- Ying-Zhao Wang
- Department of Neurology, Qianwei Hospital of Jilin Province, Changchun, China
| | - Chun Xue
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Chao Ma
- Department of Thoracic Surgery, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - An-Bang Liu
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
- Department of Cardiology, Central Hospital Affiliated to Shandong First Medical University, Jinan, China
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Li R, Lee S, Rienas W, Sarin S. Higher risk of in-hospital mortality and hepatic encephalopathy during weekend admission in Transjugular Intrahepatic Portosystemic Shunt procedure. Clin Res Hepatol Gastroenterol 2024; 48:102396. [PMID: 38876265 DOI: 10.1016/j.clinre.2024.102396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/26/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. The weekend effect refers to a higher risk of adverse outcomes associated with procedures performed on weekends compared to weekdays. The goal of this study is to determine whether a weekend effect is evident in TIPS procedures. MATERIALS AND METHOD The study identified patients who underwent TIPS procedures in the NIS database from 2015 to 2020. Patients who were admitted on the weekday or weekends were classified into two cohorts. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were noted. Multivariable analysis was used to assess outcomes. RESULTS Compared to patients admitted on the weekdays, weekend patients had higher in-hospital mortality (12.87 % vs. 7.96 %, aOR = 1.62, 95 CI 1.32-1.00, p < 0.01), hepatic encephalopathy (33.24 % vs. 26.18 %, aOR = 1.41, 95 CI 1.23-1.63, p < 0.01), acute kidney injury (39.03 % vs. 28.36 %, aOR = 1.68, 95 CI 1.46-1.93, p < 0.01), and transfer out (15.91 % vs. 12.76 %, aOR=1.33, 95 CI 1.11-1.60, p < 0.01). It was also found that weekend patients had longer wait from admission to operation (3.83 ± 0.15 days vs 2.82 ± 0.07 days, p < 0.01), longer LOS (11.22 ± 0.33 days vs 8.38 ± 0.15 days, p < 0.01), and higher total hospital charge (219,973 ± 7,352 dollars vs 172,663 ± 3,183 dollars, p < 0.01). CONCLUSION Our research unveiled a significant relationship between weekend admission and a higher risk of mortality and morbidity post-TIPS procedure. Eliminating delays in treatment associated with the weekend effect may mitigate this gap to deliver consistent and high-quality care to all patients.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, D.C., USA.
| | - SeungEun Lee
- The George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - William Rienas
- The George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - Shawn Sarin
- The George Washington University Hospital, Department of Interventional Radiology, Washington, D.C., USA
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Li R, Sarin S. The smoker's paradox in transjugular intrahepatic portosystemic shunt procedure: A national inpatient sample analysis from 2015 to 2020. Clin Res Hepatol Gastroenterol 2024; 48:102323. [PMID: 38537866 DOI: 10.1016/j.clinre.2024.102323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/07/2024] [Accepted: 03/19/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVES Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Smoking can adversely impact liver function and has been shown to influence liver-related outcomes. This study aimed to examine the impact of smoking on the immediate outcomes of TIPS procedure. MATERIALS AND METHOD The study compared smokers and non-smokers who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015 to 2020. Multivariable analysis was used to compare the in-hospital outcomes post-TIPS. Adjusted pre-procedural variables included sex, age, race, socioeconomic status, indications for TIPS, liver disease etiologies, comorbidities, and hospital characteristics. RESULTS Compared to non-smokers, smokers had lower risks of in-hospital mortality (7.36% vs 9.88 %, aOR 0.662, p < 0.01), acute kidney injury (25.57% vs 33.66 %, aOR 0.68, p < 0.01), shock (0.45% vs 0.98 %, aOR 0.467, p = 0.02), and transfer out to other hospital facilities (11.35% vs 14.78 %, aOR 0.732, p < 0.01). There was no difference in hepatic encephalopathy or bleeding. Also, smokers had shorter wait from admission to operation (2.76±0.09 vs 3.17±0.09 days, p = 0.01), shorter length of stay (7.50±0.15 vs 9.89±0.21 days, p < 0.01), and lower total hospital cost (148,721± 2,740.7 vs 204,911±4,683.5 US dollars, p < 0.01). Subgroup analyses revealed consistent patterns among both current and past smokers. CONCLUSION This study compared the immediate outcomes of smokers and non-smokers after undergoing the TIPS procedure. Interestingly, we observed a smokers' paradox, where smoker patients had better outcomes following TIPS. The underlying causes for this smoker's paradox warrant further in-depth exploration.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Shawn Sarin
- The George Washington University Hospital, Department of Interventional Radiology, Washington, DC, United State
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Li R, Sarin S. Advanced chronic renal disease is an independent risk factor for inpatient mortality following transjugular intrahepatic portosystemic shunt procedure. Eur J Gastroenterol Hepatol 2024; 36:332-337. [PMID: 38179873 DOI: 10.1097/meg.0000000000002703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. However, the risks and outcomes associated with TIPS in patients with advanced chronic kidney disease (CKD) remain uncertain. This study aimed to investigate the perioperative outcomes of TIPS procedures in patients with advanced CKD using the National Inpatient Sample (NIS) database, a comprehensive all-payer inpatient database in the US. METHODS The study identified patients who underwent TIPS procedures in the NIS database from Q4 2015 to 2020. Patients with advanced CKD were identified using specific ICD-10-CM codes, and they were compared to patients without CKD. Preoperative variables, including demographics, indications for TIPS, comorbidities, APR-DRG subclass, primary payer status, and hospital characteristics, were noted. Perioperative outcomes were examined by multivariable logistic regression. RESULTS A total of 248 patients with advanced CKD and 5511 patients without CKD undergoing TIPS procedures were identified in the NIS database. Compared to non-CKD, patients with advanced CKD had higher mortality (13.70% vs. 8.60%, aOR = 1.56, P = 0.03), acute kidney injury (51.21% vs. 29.34, aOR = 1.46, P < 0.01), transfer out (25.00% vs. 12.84%, aOR = 1.88, P < 0.01), and length of stay over 7 days (64.11% vs. 38.97%, aOR = 2.34, P < 0.01). However, there was no difference in hepatic encephalopathy (31.85% vs. 27.19%, aOR = 1.12, P = 0.42). CONCLUSION Advanced CKD patients undergoing TIPS are at higher risk of mortality and AKI compared to patients without CKD; HE was mildly elevated but NS. Long-term prognosis of patients with advanced CKD who had TIPS is needed in future studies.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Shawn Sarin
- The George Washington University Hospital, Department of Interventional Radiology, Washington, DC, USA
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Li R, Sarin S. Disparity Among African Americans in Transjugular Intrahepatic Portosystemic Shunt Procedure: A National Inpatient Sample Analysis from 2015 to 2020. Dig Dis Sci 2024; 69:713-719. [PMID: 38319431 DOI: 10.1007/s10620-024-08273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Racial disparities were present in TIPS where numerous studies suggested African American patients experience higher in-hospital mortality rates. However, the incidence of post-TIPS surgical complications, such as HE, has yet to be examined among African Americans. Therefore, this study aimed to provide a comprehensive examination of the disparities in TIPS procedures among African American patients. METHODS The study compared African American and Caucasian patients who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015-2020 after ICD-10 change. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were examined and multivariable analysis was used to assess outcomes correcting preoperative variables with p < 0.1. RESULTS Compared to Caucasians, African Americans had higher in-hospital mortality (16.18 vs 8.22%, aOR 1.781, p < 0.01), hepatic encephalopathy (33.09 vs 27.44%, aOR 1.300, p = 0.05), and acute kidney injury (45.59 vs 29.60%, aOR 2.019, p < 0.01). Using the generalized linear model, African Americans have longer length of stay (11.04 ± 0.77 days vs 8.54 ± 0.16 days, p < 0.01). CONCLUSION Despite a higher prevalence of cirrhosis, African Americans continue to have marked underrepresentation in TIPS procedures in recent years. Their underrepresentation, in conjunction with higher mortality, morbidity, and increased comorbidity conditions, could imply disparity in accessing care. This finding underscores the necessity for improved access to diagnostic and therapeutic services for African Americans with liver cirrhosis.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA.
| | - Shawn Sarin
- Department of Interventional Radiology, George Washington University Hospital, Washington, DC, USA
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Konyn P, Perumpail BJ, Wijarnpreecha K, Cholankeril G, Ahmed A, Kim D. Impact of the COVID-19 pandemic on hospitalizations with hepatocellular carcinoma in the United States. Expert Rev Gastroenterol Hepatol 2024; 18:113-119. [PMID: 38353612 DOI: 10.1080/17474124.2024.2319580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND We studied the temporal trends of hepatocellular carcinoma (HCC)-related hospitalizations and potential predictors of in-hospital mortality around the COVID-19 pandemic. RESEARCH DESIGN AND METHODS Using the International Classification of Diseases code, we used the National Inpatient Sample 2019-2020 and defined HCC and its underlying etiology. To assess the impact of the COVID-19 pandemic on hospitalization and in-hospital mortality, the study period was divided into the pre-COVID-19 era (2019 Q1-2020 Q1) and the COVID-19 era (2020 Q2-2020 Q4). Quarterly trends in etiology-based hospitalizations with HCC and predictors of in-hospital mortality among hospitalizations with HCC were determined. RESULTS Hospitalization rates for HCC, as well as viral hepatitis-related HCC hospitalization rates, remained stable, while hospitalizations with alcohol-related liver disease (ALD, quarterly percentage change [QPC]: 2.1%; 95% confidence interval [CI]: 0.1%-4.2%) increased steadily. Hospitalization related to nonalcoholic fatty liver disease (NAFLD)-related HCC increased significantly steeper in the COVID-19 era (QPC: 6.6%; 95% CI: 4.0%-9.3%) than in the pre-COVID-19 era (QPC: 0.7%; 95% CI: 0.2%-1.3%). COVID-19 infection was independently associated with in-hospital mortality among hospitalizations with HCC (odds ratio: 1.94, 95% CI: 1.30-2.88). CONCLUSION Hospitalization rates for viral hepatitis-related HCC remained stable, while those for HCC due to ALD and NAFLD increased during the COVID-19 pandemic.
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Affiliation(s)
- Peter Konyn
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Brandon J Perumpail
- Department of Pediatrics, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Karn Wijarnpreecha
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Arizona College of Medicine, Phoenix, AZ, USA
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Banner University Medical Center, Phoenix, AZ, USA
| | - George Cholankeril
- Liver Center, Division of Abdominal Transplantation, Michael E DeBakey Department of General Surgery, Baylor College of Medicine, Houston, TX, USA
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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Desai AP, Parvataneni S, Knapp SM, Nephew LD, Chalasani N, Ghabril MS, Orman ES. Hospital frailty risk score is superior to legacy comorbidity indices for risk adjustment of in-hospital cirrhosis cases. JHEP Rep 2024; 6:100955. [PMID: 38192536 PMCID: PMC10772247 DOI: 10.1016/j.jhepr.2023.100955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/17/2023] [Indexed: 01/10/2024] Open
Abstract
Background & Aims The hospital frailty risk score (HFRS) identifies older patients at risk of poor outcomes and may have value in cirrhosis. We compared the Charlson (CCI), Elixhauser (ECI), and cirrhosis (CirCom) comorbidity indices with the HFRS in predicting outcomes for cirrhosis hospitalisations. Methods Using the National Inpatient Sample (quarter 4 of 2015-2019), we analysed cirrhosis hospitalisations. For each index, we described the prevalence of comorbid conditions and inpatient mortality. We compared the ability of CCI, ECI, CirCom, and HFRS to predict inpatient mortality. Raw and adjusted models predicting inpatient mortality were compared using the area under the receiver operating characteristic curve and the Akaike information criterion. Results The cohort's (N = 626,553) median age was 61 years (IQR 52-68 years), 60% were male, cirrhosis was caused by alcohol in 43%, and 38% had ascites. The median comorbidity scores are as follows: ECI 4 (IQR 3-6), CCI 5 (IQR 4-8), and HFRS 5.6 (IQR 3.0-8.6). The most common CirCom score was 0 + 0 (44%). Across the range of values of each index, we observed different mortality ranges: CCI 1.9-13.1%, ECI 3.2-8.7%, CirCom 4.9-13.8%, and HFRS 1.0-15.2%. An adjusted model with HFRS had the highest area under the receiver operating characteristic curve in predicting mortality (HFRS 0.782 vs. ECI 0.689, CCI 0.695, and CirCom 0.692). We observed substantial variation in mortality with HFRS within each level of CCI, ECI, and CirCom. For example, for ECI 4, mortality increased from 0.6 to 16.4%, as HFRS increased from 0 to 15. Conclusions Comorbidity indices predict inpatient cirrhosis mortality, but HFRS performs better than CCI, ECI, and CirCom. HFRS is an ideal tool for measuring comorbidity burden and disease severity risk adjustment in cirrhosis-related administrative database studies. Impact and Implications We compared commonly used comorbidity indices to a more recently described risk score (hospital frailty risk score [HFRS]) in patients with cirrhosis using a national sample of hospital records. Comorbid conditions are common in hospitalised patients with cirrhosis. There is significant variability in mortality across the range of each index. HFRS outperforms the Charlson comorbidity index, Elixhauser comorbidity index, and CirCom (cirrhosis-specific comorbidity scoring system) in predicting inpatient mortality. HFRS is a valuable index for risk adjustment in inpatient administrative database studies.
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Affiliation(s)
- Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Swetha Parvataneni
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shannon M. Knapp
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Health, Indianapolis, IN, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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You HS, Kim DH, Cho SY, Park SY, Park CH, Kim HS, Choi SK. Risk factors for patients hospitalized with recurrent colon diverticular bleeding: a single center experience. Front Med (Lausanne) 2023; 10:1195051. [PMID: 38020084 PMCID: PMC10661954 DOI: 10.3389/fmed.2023.1195051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND/AIMS Colonic diverticular bleeding (CDB) is a common cause of acute lower gastrointestinal bleeding. Patients with CDB are at increased risk for recurrence. Here, we aimed to evaluate the clinical course of patients with CDB and identify risk factors for recurrent CDB (rCDB). METHODS We included patients who were hospitalized at a single tertiary center for management of CDB between January 2005 and March 2020. A Cox proportional hazards regression analysis was performed to evaluate the risk factors of patients with rCDB as follows: model 1 adjusted by age, Charlson comorbidity index (CCI), and presence of bilateral colon diverticula; model 2 adjusted by age, CCI, and presence of left side colon diverticula; model 3 adjusted by age, CCI, and presence of sigmoid colon diverticula. RESULTS Among 219 patients (mean age, 68.0 years; 55 females), 56 and 163 had definite and presumptive CDB, respectively. During the median period of 506 days, 62 patients (28.3%) experienced rCDB. CCI score ≥ 4 was independently associated with rCDB in models 1, 2 and 3 (all p < 0.05). Age ≥ 75 years was independently associated with rCDB in models 1 and 2 (both p < 0.05). The presence of bilateral colon and sigmoid colon diverticula were independently associated with rCDB in models 1 and 3, respectively (both p < 0.05). CONCLUSION rCDB frequently occurred at any time in patients with previous CDB. High CCI scores and distribution of colon diverticula were associated with rCDB. Clinicians should consider a possible rCDB for a patient considering age, comorbidity, and distribution of colon diverticula.
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Affiliation(s)
| | | | | | - Seon-Young Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | | | - Hyun-Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
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Nephew LD, Knapp SM, Mohamed KA, Ghabril M, Orman E, Patidar KR, Chalasani N, Desai AP. Trends in Racial and Ethnic Disparities in the Receipt of Lifesaving Procedures for Hospitalized Patients With Decompensated Cirrhosis in the US, 2009-2018. JAMA Netw Open 2023; 6:e2324539. [PMID: 37471085 PMCID: PMC10359964 DOI: 10.1001/jamanetworkopen.2023.24539] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 06/04/2023] [Indexed: 07/21/2023] Open
Abstract
Importance Patients with decompensated cirrhosis are hospitalized for acute management with temporizing and lifesaving procedures. Published data to inform intervention development in this area are more than a decade old, and it is not clear whether there have been improvements in disparities in the receipt of these procedures over time. Objective To evaluate the associations of race and ethnicity with receipt of procedures to treat decompensated cirrhosis over time in the US. Design, Setting, and Participants This retrospective cross-sectional study analyzed National Inpatient Sample data on cirrhosis admissions among patients with portal hypertension-related complications from 2009 to 2018. All hospital discharges for individuals aged 18 years and older from 2009 to 2018 were assessed for inclusion. Admissions were included if they contained at least 1 cirrhosis-related International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code and at least 1 cirrhosis-related complication ICD-9-CM or ICD-10-CM code (ie, ascites, hepatic encephalopathy, variceal hemorrhage [VH], and hepatorenal syndrome [HRS]). Data were analyzed from January to June 2022. Exposure Hospitalization for decompensated cirrhosis. Main Outcomes and Measures The outcomes of interest were trends in the odds ratios (ORs) for receiving procedures (upper endoscopy, transjugular portosystemic shunt [TIPS], hemodialysis, and liver transplantation [LT]) for decompensated cirrhosis and mortality by race and ethnicity, modeled over time. Multivariable logistic regression was used to assess these outcomes. Results Among 717 580 admissions (median [IQR] age, 58 [52-67] years), 345 644 patients (9.8%) were Black, 623 991 patients (17.6%) were Hispanic, and 2 340 031 patients (47.4%) were White. Based on the modeled trends, by 2018, there were no significant differences by race or ethnicity in the odds of receiving upper endoscopy for VH. However, Black patients remained less likely than White patients to undergo TIPS for VH (OR, 0.54; 95% CI, 0.47-0.62) and ascites (OR, 0.34; 95% CI, 0.31-0.38). The disparity in receipt of LT improved for Black and Hispanic patients over the study period; however, by 2018, both groups remained less likely to undergo LT than their White counterparts (Black: OR, 0.66; 95% CI, 0.61-0.70; Hispanic: OR, 0.74; 95% CI, 0.70-0.78). The odds of death in Black and Hispanic patients declined over the study period but remained higher in Black patients than White patients in 2018 (OR, 1.08; 95% CI, 1.05-1.11). Conclusions and Relevance In this cross-sectional study of individuals hospitalized with decompensated cirrhosis, there were racial and ethnic disparities in receipt of complex lifesaving procedures and in mortality that persisted over time.
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Affiliation(s)
- Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
- Indiana University Simon Comprehensive Cancer Center, Indianapolis
| | - Shannon M. Knapp
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Kawthar A. Mohamed
- Division of Medicine, University of Minnesota School of Medicine, Minneapolis
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Kavish R. Patidar
- Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
- Indiana University Simon Comprehensive Cancer Center, Indianapolis
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis
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Kim CG, Bae KS. A Comparison of the Charlson and Elixhauser Methods for Predicting Nursing Indicators in Gastrectomy with Gastric Cancer Patients. Healthcare (Basel) 2023; 11:1830. [PMID: 37444664 DOI: 10.3390/healthcare11131830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Background: Comorbidity indices such as Charlson's (CCI) and Elixhauser's (ECI) are used to adjust the patient's care, depending on the severity of their condition. However, no study has compared these indices' ability to predict nursing-sensitive outcomes (NSOs). We compared the performance of CCI and ECI in predicting NSOs in gastric cancer patients' gastrectomy. Methods: Gastric cancer patients with gastrectomy, aged 19 years or older and admitted between 2015 and 2016, were selected from the Korea Insurance Review and Assessment Service database. We examined the relationships between NSOs and CCI or ECI while adjusting patient and hospital characteristics with logistic regression. Results: The ECI item model was the best in view of the C-statistic and Akaike Information Criterion for total NSO, physiologic/metabolic derangement, and deep vein thrombosis, while the Charlson item model was the best for upper gastrointestinal tract bleeding. For the C-statistic, the ECI item model was the best for in-hospital mortality, CNS complications, shock/cardiac arrest, urinary tract infection, pulmonary failure, and wound infection, while the CCI item model was the best for hospital-acquired pneumonia and pressure ulcers. Conclusions: In predicting 8 of 11 NSOs, the ECI item model outperformed the others. For other NSOs, the best model varies between the ECI item and CCI item model.
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Affiliation(s)
- Chul-Gyu Kim
- Department of Nursing, Chungbuk National University, Cheongju 28644, Republic of Korea
| | - Kyun-Seop Bae
- Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
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12
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Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, Kanwal F. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology 2022; 76:819-853. [PMID: 35103995 PMCID: PMC9942270 DOI: 10.1002/hep.32378] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Shari S. Rogal
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare Center, Pittsburgh, Pennsylvania, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Nneka N. Ufere
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Christopher D. Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Fasiha Kanwal
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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13
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Orman ES, Yousef A, Xu C, Shamseddeen H, Johnson AW, Nephew L, Ghabril M, Desai AP, Patidar KR, Chalasani N. Palliative Care, Patient-Reported Measures, and Outcomes in Hospitalized Patients With Cirrhosis. J Pain Symptom Manage 2022; 63:953-961. [PMID: 35202730 PMCID: PMC9124687 DOI: 10.1016/j.jpainsymman.2022.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 11/18/2022]
Abstract
CONTEXT Studies of palliative care (PC) in hospitalized patients with cirrhosis have been retrospective, with limited evaluation of patient-reported measures and outcomes. OBJECTIVES To examine the relationship between PC, patient-reported measures (quality of life and functional status), and outcomes. METHODS We performed a prospective cohort study of patients with cirrhosis hospitalized from 2014 to 2019. We recorded PC consultation details, quality of life (chronic liver disease questionnaire), and functional status (functional status questionnaire). Patients were followed for 90 days to assess readmissions, costs, and mortality. RESULTS Seventy-four of 679 patients saw PC, often later in the hospitalization (median hospital day 8; IQR 4-16). Those who saw PC had greater Charlson comorbidity index (mean 6.8 vs. 5.9), MELD (mean 25 vs. 20), and prior 30-day admission (47% vs. 35%). Compared to those who did not see PC, PC patients had greater impairments in intermediate activities of daily living (83% vs. 72%), social activity (72% vs. 59%), quality of interactions (49% vs. 36%), abdominal symptoms (mean score 3.1 vs. 3.6), activity (mean 3.3 vs. 3.6), and overall quality of life (mean 3.6 vs. 3.8). PC was associated with fewer transfusions and upper endoscopies and with greater completion of advanced directives. After multivariable adjustment, PC was not associated with intensive care, 30-day readmissions, 90-day costs, or mortality. CONCLUSION PC occurs infrequently and late in those with more severe liver disease and functional impairment. PC may be associated with reduction in utilization and greater completion of advanced directives. Randomized trials are needed to evaluate PC for this population.
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Affiliation(s)
- Eric S Orman
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA.
| | - Andrew Yousef
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Chenjia Xu
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Amy W Johnson
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology (E.S.O., L.N., M.G., A.P.D., K.R.P., N.C.), Indiana University, Indianapolis, Indiana, USA; Department of Medicine (A.Y., H.S.), Indiana University, Indianapolis, Indiana, USA; Department of Biostatistics and Health Data Science (C.X.), Indiana University, Indianapolis, Indiana, USA; Division of General Internal Medicine and Geriatrics (A.W.J.), Indiana University, Indianapolis, Indiana, USA
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Zhou S, Zhang XH, Zhang Y, Gong G, Yang X, Wan WH. The Age-Adjusted Charlson Comorbidity Index Predicts Prognosis in Elderly Cancer Patients. Cancer Manag Res 2022; 14:1683-1691. [PMID: 35573259 PMCID: PMC9091471 DOI: 10.2147/cmar.s361495] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/21/2022] [Indexed: 01/01/2023] Open
Abstract
Purpose The age-adjusted Charlson comorbidity index (ACCI) is a useful measure of comorbidity to standardize the evaluation of elderly patients and has been reported to predict mortality in various cancers. To our best knowledge, no studies have examined the relationship between the ACCI and survival of elderly patients with cancer. Therefore, the primary objective of this study was to investigate the relationship between the ACCI and survival of elderly patients with cancer. Patients and Methods A total of 64 elderly patients (>80 years) with cancer between 2011 and 2021 were enrolled in this study. According to the ACCI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; patients with ACCI<11 were considered the low-ACCI group, whereas those with ACCI≥11 were considered the high-ACCI group. The correlations between the ACCI score and survival outcomes were statistically analyzed. Results There was a significant difference in overall survival (OS) and progression-free survival (PFS) between the high-ACCI group and the low-ACCI group (P<0.001). The median OS time of the high-ACCI group and the low-ACCI group were 13.9 (10.5–22.0) months and 51.9 (34.1–84.0) months, respectively. The 2-, 3-, and 5-year survival rates of the high-ACCI group were 28.1%, 18.8%, and 4.2%, respectively, whereas the 2-, 3-, and 5-year survival rates of the low-ACCI group were 77.3%, 66.4%, and 39.1%, respectively. Multivariate analysis showed that ACCI was independently associated with OS (HR=1.402, 95% CI: 1.226–1.604, P < 0.05) and PFS (HR=1.353, 95% CI: 1.085–1.688, P = 0.0073). Conclusion The ACCI score is a significant independent predictor of prognosis in elderly patients with cancer.
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Affiliation(s)
- Shi Zhou
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Xing-Hu Zhang
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Yuan Zhang
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Ge Gong
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Xiang Yang
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
| | - Wen-Hui Wan
- Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China
- Correspondence: Wen-Hui Wan, Department of Geriatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, 21002, Jiangsu, People’s Republic of China, Tel/Fax +86 25 80862433, Email
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15
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Trivedi PS, Jensen AM, Brown MA, Morgan RL, Lindrooth RC, Ryu RK, Ho PM, Kriss MS. High Prevalence of Transjugular Intrahepatic Portosystemic Shunt Creation Without Prior Endoscopy During Acute Variceal Bleeding Hospitalization in the United States. Hepatol Commun 2021; 5:1784-1790. [PMID: 34558832 PMCID: PMC8485889 DOI: 10.1002/hep4.1756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/07/2021] [Accepted: 05/06/2021] [Indexed: 11/06/2022] Open
Abstract
Current clinical guidelines by both American Association for the Study of Liver Disease and European Association for the Study of the Liver recommend endoscopy in all patients admitted with acute variceal bleeding within 12 hours of admission. Transjugular intrahepatic portosystemic shunt (TIPS) creation may be considered in patients at high risk if hemorrhage cannot be controlled endoscopically. We conducted a cross-sectional observational study to assess how frequently TIPS is created for acute variceal bleeding in the United States without preceding endoscopy. Adult patients undergoing TIPS creation for acute variceal bleeding in the United States (n = 6,297) were identified in the last 10 available years (2007-2016) of the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between endoscopy nonutilization and hospital characteristics, controlling for patient demographics, income level, insurance type, and disease severity. Of 6,297 discharges following TIPS creation for acute variceal bleeding in the United States, 31% (n = 1,924) did not receive first-line endoscopy during the same encounter. Rates of "no endoscopy" decreased with increasing population density of the hospital county (nonmicropolitan counties 43%, n = 114; mid-size metropolitan county 35%, n = 513; and central county with >1 million population 23%, n = 527) but not by hospital teaching status (n = 1,465, 32% teaching vs. n = 430, 26% nonteaching; P = 0.10). Higher disease mortality risk (odds ratio, 0.42; 95% confidence interval, 0.22-0.80; P = 0.02) was associated with lower odds of noncompliance. Conclusion: One third of all patients undergoing TIPS creation for acute variceal bleeding in the United States do not receive first-line endoscopy during the same encounter. Patients admitted to urban hospitals are more likely to receive guideline-concordant care.
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Affiliation(s)
- Premal S Trivedi
- Department of Radiology, Division of Interventional RadiologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | | | - Matthew A Brown
- Department of Radiology, Division of Interventional RadiologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | - Rustain L Morgan
- Department of Radiology, Division of Interventional RadiologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | | | - Robert K Ryu
- University of Southern California Keck School of MedicineLos AngelesCAUSA
| | - P Michael Ho
- Veterans Affairs Eastern Colorado Health SystemAuroraCOUSA
| | - Michael S Kriss
- Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
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16
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Varady NH, Gillinov SM, Yeung CM, Rudisill SS, Chen AF. The Charlson and Elixhauser Scores Outperform the American Society of Anesthesiologists Score in Assessing 1-year Mortality Risk After Hip Fracture Surgery. Clin Orthop Relat Res 2021; 479:1970-1979. [PMID: 33930000 PMCID: PMC8373577 DOI: 10.1097/corr.0000000000001772] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/11/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Risk adjustment has implications across orthopaedics, including informing clinical care, improving payment models, and enabling observational orthopaedic research. Although comorbidity indices (such as the American Society of Anesthesiologists [ASA] classification, Charlson comorbidity index [CCI], and Elixhauser comorbidity index [ECI]) have been examined extensively in the immediate perioperative period, there is a dearth of data on their three-way comparative effectiveness and long-term performance. Moreover, the discriminative ability of the CCI and ECI after orthopaedic surgery has not been validated in the ICD-10 era, despite new diagnosis codes from which they are calculated. QUESTION/PURPOSE Which comorbidity index (ASA, CCI, or ECI) is associated with the greatest accuracy on receiver operating curve (ROC) analysis with respect to the endpoint of death at 90 days and 1 year after hip fracture surgery in the ICD-10 era? METHODS A retrospective study was conducted on all patients undergoing surgical fixation of primary hip fractures at two Level I trauma centers and three community hospitals from October 2016 to May 2019. This time frame allowed for a 1-year baseline period of ICD-10 data to assess comorbidities and at least a 1-year follow-up period to assess mortality. Initially 1516 patients were identified using Common Procedural Terminology and ICD codes, of whom 4% (60 of 1516) were excluded after manual review; namely, those with pathologic fractures (n = 38), periprosthetic fractures (n = 12), and age younger than 18 years (n = 10). Of the patients who were studied, 69% (998 of 1456) were women and the mean ± SD age was 77 ± 14 years; 45% (656 of 1456) were treated with intramedullary nails, 32% (464 of 1456) underwent hemiarthroplasties, 10% (149 of 1456) underwent THAs, 7% (104 of 1456) underwent percutaneous fixations, and 6% (83 of 1456) were treated with plates and screws. The mean ± SD ASA score was 2.8 ± 0.6, CCI was 3.1 ± 3.2, and ECI was 5.2 ± 3.5. Hip fracture fixation was chosen as the operation of interest given the high incidence of this injury, the well-documented effects of comorbidities on complications, and the critical importance of risk stratification and perioperative medical management for these patients. Demographics, comorbidities, surgical details, as well as 90-day and 1-year mortality were collected. Logistic regressions with ROC curves were used to determine the accuracy and comparative effectiveness of the three measures. The 90-day mortality rate was 7.4%, and the 1-year mortality rate was 15.0%. RESULTS The accuracy (area under the curve [AUC]) for 1-year mortality was 0.685 (95% CI 0.656 to 0.714) for the ASA, 0.755 (95% CI 0.722 to 0.788) for the ECI, and 0.769 (95% CI 0.739 to 0.800) for the CCI. The CCI and ECI were more accurate than ASA (p < 0.001 for both), while the CCI and ECI did not differ (p = 0.30). The ECI (AUC 0.756 [95% CI 0.712 to 0.800]) was more accurate for 90-day mortality than the ASA (AUC 0.703 [95% CI 0.663 to 0.744]; p = 0.04), while CCI (AUC 0.742 [95% CI 0.698 to 0.785]) with ASA (p = 0.17) and CCI with ECI (p = 0.46) did not differ at 90 days. CONCLUSION Performance measures and research results may vary depending on what comorbidity index is used. We found that the CCI and ECI were more accurate than the ASA score for 1-year mortality after hip fracture surgery. Moreover, these data validate that the CCI and ECI can perform reliably in the ICD-10 era. If other studies from additional practice settings confirm these findings, as would be expected because of the objective nature of these indices, the CCI or ECI may be a useful preoperative measure for surgeons to assess 1-year mortality for hip fracture patients and should likely be used for institutional orthopaedic research involving outcomes 90 days and beyond. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Nathan H. Varady
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen M. Gillinov
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Caleb M. Yeung
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel S. Rudisill
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonia F. Chen
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Desai AP, Greene M, Nephew LD, Orman ES, Ghabril M, Chalasani N, Menachemi N. Contemporary Trends in Hospitalizations for Comorbid Chronic Liver Disease and Substance Use Disorders. Clin Transl Gastroenterol 2021; 12:e00372. [PMID: 34142663 PMCID: PMC8216677 DOI: 10.14309/ctg.0000000000000372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/28/2021] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Chronic liver diseases (CLDs) and substance use disorders (SUDs) are increasingly prevalent and often coexist. Contemporary studies describing the characteristics and hospitalization trends of those with comorbid CLD-SUD are lacking. We aimed to characterize a population-based cohort with comorbid CLD-SUD and describe trends in these hospitalizations over time by individual-level characteristics. METHODS We performed a cross-sectional analysis of the National Inpatient Sample from 2005 through 2017. Diagnosis codes were used to identify adult hospitalizations with CLD, SUD, or both. Bivariate and multivariate analyses were used to make comparisons between diagnosis categories. Unadjusted and age-adjusted trends in these hospitalizations were described over time. RESULTS Of 401,867,749 adult hospital discharges, 3.2% had CLD-only and 1.7% had comorbid CLD-SUD. Compared with CLD-only, comorbid CLD-SUD hospitalizations resulted in higher inpatient mortality (3.1% vs 2.4%, P < 0.001) and were associated with younger age, male sex, Native American race, and urban and Western US location. Over time, comorbid hospitalizations grew 34%, and the demographics shifted with larger increases in hospitalization rates seen in younger individuals, women, Native Americans, and those publicly insured. In comorbid hospitalizations, alcoholic SUD and CLD decreased, but drug SUDs and nonalcoholic fatty liver diseases are fast-growing contributors. DISCUSSION In this comprehensive analysis of US hospitalizations, comorbid CLD-SUD hospitalizations are increasing over time and lead to higher inpatient mortality than CLD alone. We further characterize the changing demographics of these hospitalizations, providing a contemporary yet inclusive look at comorbid CLD-SUD hospitalizations. These data can guide interventions needed to improve the poor outcomes suffered by this growing population.
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Affiliation(s)
- Archita P. Desai
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Marion Greene
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Lauren D. Nephew
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Eric S. Orman
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Department of Gastroenterology and Hepatology, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Nir Menachemi
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
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18
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Limam M, Matthes KL, Pestoni G, Michalopoulou E, Held L, Dehler S, Korol D, Rohrmann S. Are there sex differences among colorectal cancer patients in treatment and survival? A Swiss cohort study. J Cancer Res Clin Oncol 2021; 147:1407-1419. [PMID: 33661394 PMCID: PMC8021518 DOI: 10.1007/s00432-021-03557-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/04/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is among the three most common incident cancers and causes of cancer death in Switzerland for both men and women. To promote aspects of gender medicine, we examined differences in treatment decision and survival by sex in CRC patients diagnosed 2000 and 2001 in the canton of Zurich, Switzerland. METHODS Characteristics assessed of 1076 CRC patients were sex, tumor subsite, age at diagnosis, tumor stage, primary treatment option and comorbidity rated by the Charlson Comorbidity Index (CCI). Missing data for stage and comorbidities were completed using multivariate imputation by chained equations. We estimated the probability of receiving surgery versus another primary treatment using multivariable binomial logistic regression models. Univariable and multivariable Cox proportional hazards regression models were used for survival analysis. RESULTS Females were older at diagnosis and had less comorbidities than men. There was no difference with respect to treatment decisions between men and women. The probability of receiving a primary treatment other than surgery was nearly twice as high in patients with the highest comorbidity index, CCI 2+, compared with patients without comorbidities. This effect was significantly stronger in women than in men (p-interaction = 0.010). Survival decreased with higher CCI, tumor stage and age in all CRC patients. Sex had no impact on survival. CONCLUSION The probability of receiving any primary treatment and survival were independent of sex. However, female CRC patients with the highest CCI appeared more likely to receive other therapy than surgery compared to their male counterparts.
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Affiliation(s)
- Manuela Limam
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Cancer Registry Zurich, Zug, Schaffhausen and Schwyz, University Hospital Zurich, Zurich, Switzerland
| | - Katarina Luise Matthes
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Cancer Registry Zurich, Zug, Schaffhausen and Schwyz, University Hospital Zurich, Zurich, Switzerland
| | - Giulia Pestoni
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Cancer Registry Zurich, Zug, Schaffhausen and Schwyz, University Hospital Zurich, Zurich, Switzerland
| | | | - Leonhard Held
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Silvia Dehler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Cancer Registry Zurich, Zug, Schaffhausen and Schwyz, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri Korol
- Cancer Registry Zurich, Zug, Schaffhausen and Schwyz, University Hospital Zurich, Zurich, Switzerland
| | - Sabine Rohrmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
- Cancer Registry Zurich, Zug, Schaffhausen and Schwyz, University Hospital Zurich, Zurich, Switzerland.
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Trivedi PS, Jensen AM, Kriss MS, Brown MA, Morgan RL, Lindrooth RC, Ho PM, Ryu RK. Ethnoracial Disparity in Hospital Survival following Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Variceal Bleeding in the United States. J Vasc Interv Radiol 2021; 32:941-949.e3. [PMID: 33901695 DOI: 10.1016/j.jvir.2021.02.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To investigate the magnitude of racial/ethnic differences in hospital mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding and whether hospital care processes contribute to them. METHODS Patients aged ≥18 years undergoing TIPS creation for acute variceal bleeding in the United States (n = 10,331) were identified from 10 years (2007-2016) available in the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between patient race and inpatient mortality, controlling for disease severity, treatment utilization, and hospital characteristics. RESULTS A total of 6,350 (62%) patients were White, 1,780 (17%) were Hispanic, and 482 (5%) were Black. A greater proportion of Black patients were admitted to urban teaching hospitals (Black, n = 409 (85%); Hispanic, n = 1,310 (74%); and White, n = 4,802 (76%); P < .001) and liver transplant centers (Black, n = 215 (45%); Hispanic, n = 401 (23%); and White, n = 2,267 (36%); P < .001). Being Black was strongly associated with mortality (Black, 32% vs non-Black, 15%; odds ratio, 3.0 [95% confidence interval, 1.6-5.8]; P = .001), as assessed using the risk-adjusted regression model. This racial disparity disappeared in a sensitivity analysis including only patients with a maximum Child-Pugh score of 13 (odds ratio 1.2 [95% confidence interval, 0.4-3.6]; P = .68), performed to compensate for the absence of Model for End-stage Liver Disease scores. Ethnoracial differences in access to teaching hospitals, liver transplant centers, first-line endoscopy, and transfusion did not significantly contribute (P > .05) to risk-adjusted mortality. CONCLUSIONS Black patients have a 2-fold higher inpatient mortality than non-Black patients following TIPS creation for acute variceal bleeding, possibly related to greater disease severity before the procedure.
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Affiliation(s)
- Premal S Trivedi
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | | | - Michael S Kriss
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Matthew A Brown
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rustain L Morgan
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - P Michael Ho
- Division of Cardiology, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Robert K Ryu
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Radiology, University of Southern California, Los Angeles, California
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Lancellotti F, Solinas L, Sagnotta A, Mancini S, Cosentino LPM, Belardi A, Battaglia B, Mirri MA, Ciabattoni A, Salerno F, Loponte M. Short course radiotherapy and delayed surgery for locally advanced rectal cancer in frail patients: is it a valid option? Eur J Surg Oncol 2021; 47:2046-2052. [PMID: 33757649 DOI: 10.1016/j.ejso.2021.03.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/28/2020] [Accepted: 03/06/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE The endpoint of the present study was to evaluate the outcomes of short-course radiotherapy (SCRT) and SCRT with delayed surgery (SCRT-DS) on a selected subgroup of frail patients with locally advanced middle/low rectal adenocarcinoma. METHODS From January 2008 to December 2018, a total of 128 frail patients with locally advanced middle-low rectal adenocarcinoma underwent SCRT and subsequent restaging for eventual delayed surgery. Rates of complete pathological response, down-staging, disease free survival (DFS) and overall survival (OS) were analyzed. RESULTS 128 patients completed 5 × 5 Gy pelvic radiotherapy. 69 of these were unfit for surgery; 59 underwent surgery 8 weeks (average time: 61 days) after radiotherapy. Downstaging of T occurred in 64% and down-staging of N in 50%. The median overall survival (OS) of SCRT alone was 19.5 months. The 1-year, 2-year, 3-year and 5-year OS was 48%, 22%, 14% and 0% respectively. In the surgical group, the median disease-free survival (DFS) and median OS were, respectively, 67 months (95% CI 49.8-83.1 months) and 72.1 months (95% CI 57.5-86.7 months). The 1, 2, 3, 5-year OS was 88%, 75%, 51%, 46%, respectively. Post-operative morbidity was 22%, mortality was 3.4%. CONCLUSIONS Frail patients with advanced rectal cancer are often "unfit" for long-term neoadjuvant chemoradiation. A SCRT may be considered a valid option for this group of patients. Once radiotherapy is completed, patients can be re-evaluated for surgery. If feasible, SCRT and delayed surgery is the best option for frail patients.
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Affiliation(s)
| | - Luigi Solinas
- Department of General Surgery and Surgical Oncology, San Filippo Neri Hospital, Rome, Italy.
| | - Andrea Sagnotta
- Department of General Surgery and Surgical Oncology, San Filippo Neri Hospital, Rome, Italy.
| | - Stefano Mancini
- Department of General Surgery and Surgical Oncology, San Filippo Neri Hospital, Rome, Italy.
| | | | - Augusto Belardi
- Department of General Surgery and Surgical Oncology, San Filippo Neri Hospital, Rome, Italy.
| | - Benedetto Battaglia
- Department of General Surgery and Surgical Oncology, San Filippo Neri Hospital, Rome, Italy.
| | | | | | | | - Margherita Loponte
- Department of Emergency Surgery, San Filippo Neri Hospital, Rome, Italy.
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Carbonneau M, Davyduke T, Congly SE, Ma MM, Newnham K, Den Heyer V, Tandon P, Abraldes JG. Impact of specialized multidisciplinary care on cirrhosis outcomes and acute care utilization. CANADIAN LIVER JOURNAL 2021; 4:38-50. [PMID: 35991472 PMCID: PMC9203164 DOI: 10.3138/canlivj-2020-0017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/27/2020] [Indexed: 09/15/2023]
Abstract
Background Multidisciplinary care has the potential to improve outcomes among patients with cirrhosis, yet its impact on this population remains unclear, with existing studies demonstrating discrepant results. Using data from the multidisciplinary outpatient Cirrhosis Care Clinic (CCC) at the University of Alberta Hospital, we aimed to evaluate acute care utilization and survival outcomes of patients followed by the CCC compared with those receiving standard care (SC). Methods We performed a retrospective chart review of 212 patients with cirrhosis admitted to University of Alberta Hospital between 2014 and 2015. CCC patients (n = 36) were followed through the CCC before index admission. SC patients (n = 176) were managed outside of the CCC. Readmission time in hospital was collected until 1 year, death, or liver transplant. Results CCC patients had more advanced liver disease (higher prevalence of ascites, encephalopathy, and varices). Despite this, acute care utilization was significantly lower among CCC patients (adjusted length of stay lower by 3 days, p = 0.03, and adjusted survival days spent in hospital lower by 9%, p = 0.02). CCC patients also had improved 1-year transplant-free survival, with an adjusted 1-year relative risk reduction of 53% (p = 0.03). Total mean cost of care was lower in the CCC group by $2,280 per patient-month of life. Discussion For patients admitted with cirrhosis, specialized post-discharge multidisciplinary outpatient care is associated with decreased acute care utilization, improved 1-year transplant-free survival probability, and the potential for cost savings to the system.
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Affiliation(s)
| | - Tracy Davyduke
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Stephen E Congly
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
| | - Mang M Ma
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Kim Newnham
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Vanessa Den Heyer
- Hepatology Department, Alberta Health Services, Edmonton, Alberta, Canada
| | - Puneeta Tandon
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Calgary, Calgary, Alberta, Canada
- Liver Unit, Division of Gastroenterology, Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
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Differences in the Predictive value of Elixhauser Comorbidity Index and the Charlson Comorbidity indices in patients with hand infections. J Clin Orthop Trauma 2020; 16:27-34. [PMID: 33680828 PMCID: PMC7919929 DOI: 10.1016/j.jcot.2020.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/18/2020] [Accepted: 12/01/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hand infections are a common source of potentially debilitating morbidity, particularly in patients with comorbid disease. We hypothesize that there is a difference in predictive value between two commonly used comorbidity indices for the prognosis of hand infections, which may have clinical implications in the management of these conditions. METHODS The Nationwide Inpatient Sample 2001-2013 database was queried for hand infections using International Classification of Diseases, Ninth Revision codes. The Elixhauser (ECI) and Charlson (CCI) comorbidity scores were calculated based on validated sets of ICD-9 codes. Primary outcomes included mortality, prolonged length of stay (LOS, defined as >95 percentile), discharge destination, and postoperative complications. Indices were compared using receiver operating characteristic (ROC) curves and the areas under the curve (AUC). If confidence intervals overlapped, significance was determined using the DeLong method for correlated ROC curves. This is a validated, non-parametric comparison used for the calculation of the difference between two AUCs. RESULTS A weighted total of 1,511,057 patients were included in this study. The majority were Caucasian (57.1%) males (61.4%). Complication rates included 0.9% mortality, 5.3% prolonged length of stay, 25.3% discharges to non-home destinations, and 5.3% post-operative complications. The ECI and CCI each demonstrated good predictive value for mortality, but poor predictive value for non-routine discharge, prolonged LOS, and post-operative complications. There was a significantly increased likelihood of each complication with increasing comorbidity score for both indices, with the greatest odds ratio in the ECI ≥4 cohort. CONCLUSIONS The CCI was superior in predicting mortality while the ECI was superior in predicting non-routine discharge, prolonged length of stay, and postoperative complications, but these indices may not be clinically relevant. While both represent good predictive models, a score specifically designed for patients with hand infections may have superior prognostic value. LEVEL OF EVIDENCE Level IV.
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Are VS, Knapp SM, Banerjee A, Shamseddeen H, Ghabril M, Orman E, Patidar KR, Chalasani N, Desai AP. Improving Outcomes of Bariatric Surgery in Patients With Cirrhosis in the United States: A Nationwide Assessment. Am J Gastroenterol 2020; 115:1849-1856. [PMID: 33156104 PMCID: PMC8021461 DOI: 10.14309/ajg.0000000000000911] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION With increasing burden of obesity and liver disease in the United States, a better understanding of bariatric surgery in context of cirrhosis is needed. We described trends of hospital-based outcomes of bariatric surgery among cirrhotics and determined effect of volume status and type of surgery on these outcomes. METHODS In this population-based study, admissions for bariatric surgery were extracted from the National Inpatient Sample using International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes from 2004 to 2016 and grouped by cirrhosis status, type of bariatric surgery, and center volume. In-hospital mortality, complications, and their trends were compared between these groups using weighted counts, odds ratios [ORs], and logistic regression. RESULTS Among 1,679,828 admissions for bariatric surgery, 9,802 (0.58%) had cirrhosis. Cirrhosis admissions were more likely to be in white men, had higher Elixhauser Index, and higher in-hospital complications rates including death (1.81% vs 0.17%), acute kidney injury (4.5% vs 1.2%), bleeding (2.9% vs 1.1%), and operative complications (2% vs 0.6%) (P < 0.001 for all) compared to those without cirrhosis. Overtime, restrictive surgeries have grown in number (12%-71%) and complications rates have trended down in both groups. Cirrhotics undergoing bariatric surgery at low-volume centers (<50 procedures per year) and nonrestrictive surgery had a higher inpatient mortality rate (adjusted OR 4.50, 95% confidence interval 3.14-6.45, adjusted OR 4.00, 95% confidence interval 2.68-5.97, respectively). DISCUSSION Contemporary data indicate that among admissions for bariatric surgery, there is a shift to restrictive-type surgeries with an improvement in-hospital complications and mortality. However, patients with cirrhosis especially those at low-volume centers have significantly higher risk of worse outcomes (see Visual abstract, Supplementary Digital Content, http://links.lww.com/AJG/B648).
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Affiliation(s)
- Vijay S. Are
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shannon M. Knapp
- University of Arizona Health Sciences and Bio5 Institute, Tucson, Arizona, USA
| | - Ambar Banerjee
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis Indiana, USA
- Indiana Center for Liver Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Changing epidemiology and outcomes of acute kidney injury in hospitalized patients with cirrhosis - a US population-based study. J Hepatol 2020; 73:1092-1099. [PMID: 32387698 PMCID: PMC7994029 DOI: 10.1016/j.jhep.2020.04.043] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Acute kidney injury (AKI) is a significant clinical event in cirrhosis yet contemporary population-based studies on the impact of AKI on hospitalized cirrhotics are lacking. We aimed to characterize longitudinal trends in incidence, healthcare burden and outcomes of hospitalized cirrhotics with and without AKI using a nationally representative dataset. METHODS Using the 2004-2016 National Inpatient Sample (NIS), admissions for cirrhosis with and without AKI were identified using ICD-9 and ICD-10 codes. Regression analysis was used to analyze the trends in hospitalizations, costs, length of stay and inpatient mortality. Descriptive statistics, simple and multivariable logistic regression were used to assess associations between individual characteristics, comorbidities, and cirrhosis complications with AKI and death. RESULTS In over 3.6 million admissions for cirrhosis, 22% had AKI. AKI admissions were more costly (median $13,127 [IQR $7,367-$24,891] vs. $8,079 [IQR $4,956-$13,693]) and longer (median 6 [IQR 3-11] days vs. 4 [IQR 2-7] days). Over time, AKI prevalence doubled from 15% in 2004 to 30% in 2016. CKD was independently and strongly associated with AKI (adjusted odds ratio 3.75; 95% CI 3.72-3.77). Importantly, AKI admissions were 3.75 times more likely to result in death (adjusted odds ratio 3.75; 95% CI 3.71-3.79) and presence of AKI increased risk of mortality in key subgroups of cirrhosis, such as those with infections and portal hypertension-related complications. CONCLUSIONS The prevalence of AKI is significantly increased among hospitalized cirrhotics. AKI substantially increases the healthcare burden associated with cirrhosis. Despite advances in cirrhosis care, a significant gap remains in outcomes between cirrhotics with and without AKI, suggesting that AKI continues to represent a major clinical challenge. LAY SUMMARY Sudden damage to the kidneys is becoming more common in people who are hospitalized and have cirrhosis. Despite advances in cirrhosis care, those with damage to the kidneys remain at higher risk of dying.
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Abstract
The prevalence of cirrhosis is increasing despite advances in therapeutics, and it remains an expensive medical condition. Studies examining the healthcare burden of inpatient cirrhosis-related care regardless of etiology, stage, or severity are lacking. This study aims to describe the current drivers of cost, length of stay (LOS), and mortality in hospitalized patients with cirrhosis.
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Kim S, Kim DH, Park SY, Park CH, Kim HS, Choi SK, Rew JS. Association between Charlson comorbidity index and complications of endoscopic resection of gastric neoplasms in elderly patients. BMC Gastroenterol 2020; 20:213. [PMID: 32646468 PMCID: PMC7346434 DOI: 10.1186/s12876-020-01360-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 06/30/2020] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Although endoscopic resection is safe and effective for gastric epithelial neoplasms, information is limited on its efficacy and safety in extremely elderly patients who have various comorbidities. Further, the relationship between comorbidities and complications of endoscopic resection is not well established. Therefore, we aimed to evaluate the efficacy and safety of endoscopic resection of gastric epithelial neoplasms in extremely elderly patients. METHODS From October 2008 to December 2017, 4475 consecutive patients underwent endoscopic resection of gastric epithelial neoplasms. Among them, 242 were 75 years or older. We assessed Charlson comorbidity index (CCI) scores, procedural outcomes, and procedure- and sedation-related complications related to endoscopic resection. RESULTS Mean patient age was 78.7 ± 3.2 years. Of the 242 patients, 124 (51.2%) had low-grade dysplasia and 112 (46.3%) had adenocarcinoma. The most common comorbidity was hypertension (55.4%), followed by diabetes (23.1%). The mean CCI score was 1.67 ± 1.43. Sixty patients (24.8%) had a CCI score ≥ 3. During the procedure, 10 (4.1%) patients had desaturation that recovered by flumazenil use with mask (n = 2) or Ambu bag (n = 3) ventilation. During subsequent admission, atelectasis or pneumonia occurred in 45 (18.6%) patients, post-procedural bleeding in 12 (5.0%), and perforation in 3 (1.2%). Respiratory complications were more common in patients with a CCI score ≥ 3 (20/60, 33.3%) than in those with a CCI score < 3 (25/182, 13.7%, P = 0.002). CONCLUSIONS CCI score is related to respiratory complications of endoscopic resection in extremely elderly patients. Endoscopic resection must be performed cautiously, particularly in elderly patients with a high CCI score, to prevent respiratory complications.
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Affiliation(s)
- Sunmin Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National Medical School, Gwangju, South Korea
| | - Dong Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National Medical School, Gwangju, South Korea
| | - Seon-Young Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National Medical School, Gwangju, South Korea
| | - Chang Hwan Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National Medical School, Gwangju, South Korea
| | - Hyun Soo Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National Medical School, Gwangju, South Korea
| | - Sung Kyu Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National Medical School, Gwangju, South Korea
| | - Jong Sun Rew
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National Medical School, Gwangju, South Korea
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Stahl CC, Schwartz PB, Leverson GE, Barrett JR, Aiken T, Acher AW, Ronnekleiv-Kelly SM, Minter RM, Weber SM, Abbott DE. Summary perioperative risk metrics within the electronic medical record predict patient-level cost variation in pancreaticoduodenectomy. Surgery 2020; 168:274-279. [PMID: 32349869 DOI: 10.1016/j.surg.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/30/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Automated data extraction from the electronic medical record is fast, scalable, and inexpensive compared with manual abstraction. However, concerns regarding data quality and control for underlying patient variation when performing retrospective analyses exist. This study assesses the ability of summary electronic medical record metrics to control for patient-level variation in cost outcomes in pancreaticoduodenectomy. METHODS Patients that underwent pancreaticoduodenectomy from 2014 to 2018 at a single institution were identified within the electronic medical record and linked with the National Surgical Quality Improvement Program. Variables in both data sets were compared using interrater reliability. Logistic and linear regression modelling of complications and costs were performed using combinations of comorbidities/summary metrics. Models were compared using the adjusted R2 and Akaike information criterion. RESULTS A total of 117 patients populated the final data set. A total of 31 (26.5%) patients experienced a complication identified by the National Surgical Quality Improvement Program. The median direct variable cost for the encounter was US$14,314. Agreement between variables present in the electronic medical record and the National Surgical Quality Improvement Program was excellent. Stepwise linear regression models of costs, using only electronic medical record-extractable variables, were non-inferior to those created with manually abstracted individual comorbidities (R2 = 0.67 vs 0.30, Akaike information criterion 2,095 vs 2,216). Model performance statistics were minimally impacted by the addition of comorbidities to models containing electronic medical record summary metrics (R2 = 0.67 vs 0.70, Akaike information criterion 2,095 vs 2,088). CONCLUSION Summary electronic medical record perioperative risk metrics predict patient-level cost variation as effectively as individual comorbidities in the pancreaticoduodenectomy population. Automated electronic medical record data extraction can expand the patient population available for retrospective analysis without the associated increase in human and fiscal resources that manual data abstraction requires.
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Affiliation(s)
- Christopher C Stahl
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Patrick B Schwartz
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Glen E Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - James R Barrett
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Taylor Aiken
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Alexandra W Acher
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sean M Ronnekleiv-Kelly
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Rebecca M Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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Holden JH, Shamseddeen H, Johnson AW, Byriel B, Subramoney K, Cheng YW, Saito A, Ghabril M, Chalasani N, Sachs GA, Orman ES. Palliative Care and Hospice Referrals in Patients with Decompensated Cirrhosis: What Factors Are Important? J Palliat Med 2020; 23:1066-1075. [PMID: 32091954 DOI: 10.1089/jpm.2019.0501] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Palliative care (PC) and hospice care are underutilized for patients with end-stage liver disease, but factors associated with these patterns of utilization are not well understood. Objective: We examined patient-level factors associated with both PC and hospice referrals in patients with decompensated cirrhosis (DC). Design: Retrospective cohort study. Setting/Subjects: Patients with DC hospitalized at a single tertiary center and followed for one year. Measurements: We assessed PC and hospice referrals during follow-up and examined patient-level factors associated with the receipt of PC and/or hospice, as well as associated clinical outcomes. We also examined late referrals (within one week of death). Results: Of 397 patients, 61 (15.4%) were referred to PC, 71 (17.9%) were referred to hospice, and 99 (24.9%) were referred to PC and/or hospice. Two hundred patients (50.4%) died during the one-year follow-up. In multivariable logistic regression, referral to PC was associated with increased comorbidity burden, ascites, increased MELD (Model for End-Stage Liver Disease)-Na score, lack of listing for liver transplant, and unmarried status. Hospice referral was associated with increased comorbidities, portal vein thrombosis, and hepatocellular carcinoma. PC referrals were late in 68.5% of cases, and hospice referrals were late in 62.7%. Late PC referrals were associated with younger age and married status. Late hospice referrals were associated with younger age and recent alcohol use. Conclusions: PC and hospice is underutilized in patients with DC, and most referrals are late. Patient-level factors associated with these referrals differ between PC and hospice.
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Affiliation(s)
- John H Holden
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Amy W Johnson
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA
| | - Benjamin Byriel
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Kavitha Subramoney
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA
| | - Yao-Wen Cheng
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California, USA
| | - Akira Saito
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Greg A Sachs
- Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis, Indiana, USA.,Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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Trivedi PS, Brown MA, Rochon PJ, Ryu RK, Johnson DT. Gender Disparity in Inpatient Mortality After Transjugular Intrahepatic Portosystemic Shunt Creation in Patients Admitted With Hepatorenal Syndrome: A Nationwide Study. J Am Coll Radiol 2020; 17:231-237. [DOI: 10.1016/j.jacr.2019.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 12/30/2022]
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Olaiya B, Adler DG. Air embolism secondary to endoscopy in hospitalized patients: results from the National Inpatient Sample (1998-2013). Ann Gastroenterol 2019; 32:476-481. [PMID: 31474794 PMCID: PMC6686097 DOI: 10.20524/aog.2019.0401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/19/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Air embolism is a rare, but potentially catastrophic complication of endoscopic procedures. We herein evaluated the overall incidence of air embolism after endoscopy. We also measured mortality outcomes after air embolism. Methods: Patients who underwent endoscopy as an index procedure during hospitalization were selected from the National Inpatient Sample from 1998-2013. The primary outcome of interest was the incidence of air embolism after endoscopy. All-cause mortality after endoscopy was measured as a secondary outcome and the Charlson Comorbidity Index was calculated. Binary logistic regression was used to explore the effect of air embolism on inpatient mortality, using P<0.05 as level of significance. Results: A total of 2,245,291 patients met the inclusion criteria. Mean age at the time of procedure was 62.5 years. Esophagogastroduodenoscopy (EGD) was the most common endoscopic procedure, accounting for 80% of endoscopic procedures. Air embolism occurred in 13 cases, giving a rate of 0.57 per 100,000 endoscopic procedures. Air embolism was most common after endoscopic retrograde cholangiopancreatography (ERCP), occurring in 3.32 per 100,000 procedures, compared with 0.44 and 0.38 per 100,000 procedures for EGD and colonoscopy, respectively. The case fatality rate for post endoscopic air embolism was 15.4%. After adjusting for covariates, air embolism after endoscopy was independently associated with higher odds of inpatient mortality: odds ratio 10.35, 95% confidence interval 1.21-88.03 (P<0.03). Conclusions: Air embolism is most common after ERCP. It is frequently associated with disorders involving a breach to the gastrointestinal mucosa or vasculature. Though rare, it is an independent predictor of inpatient mortality.
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Affiliation(s)
- Babatunde Olaiya
- Department of Internal Medicine, Marshfield Clinic, Marshfield WI (Babatunde Olaiya)
| | - Douglas G Adler
- Department of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah (Douglas G. Adler), USA
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Ross KH, Patzer RE, Goldberg D, Osborne NH, Lynch RJ. Rural-Urban Differences in In-Hospital Mortality Among Admissions for End-Stage Liver Disease in the United States. Liver Transpl 2019; 25:1321-1332. [PMID: 31206223 DOI: 10.1002/lt.25587] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 06/10/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Katherine H Ross
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Emory University, Atlanta, GA
| | - Rachel E Patzer
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Emory University, Atlanta, GA.,Division of Transplantation, Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA
| | - David Goldberg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nicolas H Osborne
- Division of Vascular Surgery, Department of Surgery, School of Medicine, University of Michigan, Ann Arbor, MI
| | - Raymond J Lynch
- Department of Epidemiology, Rollins School of Public Health, Emory University School of Medicine, Emory University, Atlanta, GA.,Division of Transplantation, Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA
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Kim LH, Chen YR. Risk Adjustment Instruments in Administrative Data Studies: A Primer for Neurosurgeons. World Neurosurg 2019; 128:477-500. [DOI: 10.1016/j.wneu.2019.04.179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/19/2019] [Accepted: 04/20/2019] [Indexed: 11/25/2022]
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Orman ES, Roberts A, Ghabril M, Nephew L, Desai A, Patidar K, Chalasani N. Trends in Characteristics, Mortality, and Other Outcomes of Patients With Newly Diagnosed Cirrhosis. JAMA Netw Open 2019; 2:e196412. [PMID: 31251379 PMCID: PMC6604080 DOI: 10.1001/jamanetworkopen.2019.6412] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Changes in the characteristics of patients with cirrhosis are likely to affect future outcomes and are important to understand in planning for the care of this population. OBJECTIVE To identify changes in demographic and clinical characteristics and outcomes in patients with newly diagnosed cirrhosis. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of patients with a new diagnosis of cirrhosis was conducted using the Indiana Network for Patient Care, a large statewide regional health information exchange, between 2004 and 2014. Patients with at least 1 year of continuous follow-up before the cirrhosis diagnosis were followed up through August 1, 2015. The analysis was conducted from December 2018 to January 2019. EXPOSURES Age, cause of cirrhosis, and year of diagnosis. MAIN OUTCOMES AND MEASURES Overall rates for mortality, liver transplant, hepatocellular carcinoma, and hepatic decompensation (composite of ascites, hepatic encephalopathy, or variceal bleeding). RESULTS A total of 9261 patients with newly diagnosed cirrhosis were identified (mean [SD] age, 57.9 [12.6] years; 5109 [55.2%] male). A 69% increase in new diagnoses occurred over the course of the study period (620 in 2004 vs 1045 in 2014). The proportion of those younger than 40 years increased by 0.20% per year (95% CI, 0.04% to 0.36%; P for trend = .02), and the proportion of those aged 65 years and older increased by 0.81% per year (95% CI, 0.51% to 1.11%; P for trend < .001). The proportion of patients with alcoholic cirrhosis increased by 0.80% per year (95% CI, 0.49% to 1.12%), and the proportion with nonalcoholic steatohepatitis increased by 0.59% per year (95% CI, 0.30% to 0.87%), whereas the proportion with viral hepatitis decreased by 1.36% per year (95% CI, -1.68% to -1.03%) (P < .001 for all). In patients younger than 40 years, 40 to 64 years, and 65 years and older, mortality rates were 6.4 (95% CI, 5.4 to 7.6), 9.9 (95% CI, 9.5 to 10.4), and 16.2 (95% CI, 15.2 to 17.2) per 100 person-years, respectively (P < .001). Mortality rates decreased during the study period (11.9 [95% CI, 10.7-13.1] per 100 person-years in 2004 vs 10.0 [95% CI, 8.1-12.2] per 100 person-years in 2014; annual adjusted hazard ratio, 0.87 [95% CI, 0.86 to 0.88]) and were lower in those with alcoholic cirrhosis compared with patients with viral hepatitis (adjusted hazard ratio, 0.89 [95% CI, 0.80 to 0.98]). Rates of hepatocellular carcinoma were low in patients younger than 40 years (0.5 [95% CI, 0.2 to 0.9] per 100 person-years). Liver transplant rates were low throughout the study period (0.3 [95% CI, 0.3-0.4] per 100 person-years). In patients with compensated cirrhosis, rates of hepatic decompensation were lower in patients younger than 40 years (adjusted subhazard ratio 0.78; 95% CI, 0.62 to 0.99) and in patients with nonalcoholic steatohepatitis (adjusted subhazard ratio, 0.51; 95% CI, 0.43 to 0.60). CONCLUSIONS AND RELEVANCE The population of patients with newly diagnosed cirrhosis in Indiana has experienced changes in the age distribution and cause of cirrhosis, with decreasing mortality rates. These findings support investment in the prevention and treatment of alcoholic liver disease and nonalcoholic steatohepatitis, particularly in younger and older patients. Additional study is needed to identify the reasons for decreasing mortality rates.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Anna Roberts
- Regenstrief Institute, Inc, Indianapolis, Indiana
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Archita Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Kavish Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis
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Arisar FAQ, Abid S, Shaikh PA, Awan S. Impact of sepsis and non-communicable diseases on prognostic models to predict the outcome of hospitalized chronic liver disease patients. World J Hepatol 2018; 10:944-955. [DOI: doi.org/10.4254/wjh.v10.i12.944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Qazi Arisar FA, Abid S, Shaikh PA, Awan S. Impact of sepsis and non-communicable diseases on prognostic models to predict the outcome of hospitalized chronic liver disease patients. World J Hepatol 2018; 10:944-955. [PMID: 30631399 PMCID: PMC6323522 DOI: 10.4254/wjh.v10.i12.944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/07/2018] [Accepted: 10/17/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the impact of sepsis and non-communicable diseases (NCDs) on the outcome of decompensated chronic liver disease (CLD) patients. METHODS In this cross-sectional study, medical records of patients with CLD admitted to the Gastroenterology unit at the Aga Khan University Hospital were reviewed. Patients older than 18 years with decompensation of CLD (i.e., jaundice, ascites, encephalopathy, and/or upper gastrointestinal bleed) as the primary reason for admission were included, while those who were admitted for reasons other than decompensation of CLD were excluded. Each patient was followed for 6 wk after index admission to assess mortality, prolonged hospital stay (> 5 d), and early readmission (within 7 d). RESULTS A total of 399 patients were enrolled. The mean age was 54.3 ± 11.7 years and 64.6% (n = 258) were male. Six-week mortality was 13% (n = 52). Prolonged hospital stay and readmission were present in 18% (n = 72) and 7% (n = 28) of patients, respectively. NCDs were found in 47.4% (n = 189) of patients. Acute kidney injury, sepsis, and non-ST elevation myocardial infarction were found in 41% (n = 165), 17.5% (n = 70), and 1.75% (n = 7) of patients, respectively. Upon multivariate analysis, acute kidney injury, non-ST elevation myocardial infarction, sepsis, and coagulopathy were found to be statistically significant predictors of mortality. While chronic kidney disease (CKD), low albumin, and high Model for End-Stage Liver Disease (MELD)-Na score were found to be statistically significant predictors of morbidity. Addition of sepsis in conventional MELD score predicted mortality even better than MELD-Na (area under receiver operating characteristic: 0.735 vs 0.686; P < 0.001). Among NCDs, CKD was found to increase morbidity independently. CONCLUSION Addition of sepsis improved the predictability of MELD score as a prognostic marker for mortality in patients with CLD. Presence of CKD increases the morbidity of patients with CLD.
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Affiliation(s)
- Fakhar Ali Qazi Arisar
- Section of Gastroenterology, Department of Medicine, Faculty Offices Building, the Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Shahab Abid
- Section of Gastroenterology, Department of Medicine, Faculty Offices Building, the Aga Khan University Hospital, Karachi 74800, Pakistan.
| | - Preet Ayoub Shaikh
- Section of Gastroenterology, Department of Medicine, Faculty Offices Building, the Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Safia Awan
- Section of Gastroenterology, Department of Medicine, Faculty Offices Building, the Aga Khan University Hospital, Karachi 74800, Pakistan
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Sarwar A, Zhou L, Novack V, Tapper EB, Curry M, Malik R, Ahmed M. Hospital volume and mortality after transjugular intrahepatic portosystemic shunt creation in the United States. Hepatology 2018; 67:690-699. [PMID: 28681542 DOI: 10.1002/hep.29354] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 06/26/2017] [Accepted: 06/27/2017] [Indexed: 12/14/2022]
Abstract
The link between higher procedure volume and better outcomes for surgical procedures is well established. We aimed to determine whether procedure volume affected inpatient mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). An epidemiological analysis of an all-payer database recording hospitalizations during 2013 in the United States (Nationwide Readmissions Database) was performed. All patients ≥ 18 years old undergoing TIPS during a hospital admission (n = 5529) without concurrent or prior liver transplantation were selected. All-cause inpatient mortality was assessed. Risk-adjusted mortality was assessed for hospitals categorized into quintiles based on annual TIPS volume (very low, 1-4/year; low, 5-9/year; medium, 10-19/year; high, 20-29/year; and very high, ≥ 30/year). TIPS were placed in all 5529 patients (mean age, 57 years [standard deviation, ± 10.9 years]; women, n = 2071; men, n = 3458). Mortality decreased with rising annual TIPS volume (13% for very low to 6% for very high volume hospitals; P < 0.01). Elective admissions were more common in hospitals with higher annual TIPS volume (20.3% for very low to 30.8% for very high; P < 0.01). On multivariate analysis, compared with hospitals performing ≥30 TIPS per year, only hospitals performing 1-4/year (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.21-3.01; P = 0.01), 5-9/year (aOR, 2.0; 95% CI, 1.25-3.17; P < 0.01), and 10-19/year (aOR, 1.9; 95% CI, 1.17-3.00; P = 0.01) had higher inpatient mortality (20-29/year: aOR, 1.4; 95% CI, 0.84-2.84; P = 0.19). The absolute difference between risk-adjusted mortality rate for very low volume and very high volume hospitals was 6.1% (13.9% versus 7.8%). TIPS volume of ≤ 20 TIPS/year, variceal bleeding, and nosocomial infections were independent risk factors for inpatient mortality in patients with both elective and emergent admissions. Conclusion: The risk of inpatient mortality is lower in hospitals performing ≥20 TIPS per year. Future research exploring preventable factors for higher mortality and benefits of patient transfer to higher volume centers is warranted. (Hepatology 2018;67:690-699).
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Affiliation(s)
- Ammar Sarwar
- Division of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Lujia Zhou
- Division of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center and Faculty of Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA.,Division of Gastroenterology, Department of Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Michael Curry
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Raza Malik
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Muneeb Ahmed
- Division of Vascular and Interventional Radiology, Department of Radiology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
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Petersen MW, Skovenborg EL, Rask CU, Høeg MD, Ørnbøl E, Schröder A. Physical comorbidity in patients with multiple functional somatic syndromes. A register-based case-control study. J Psychosom Res 2018; 104:22-28. [PMID: 29275781 DOI: 10.1016/j.jpsychores.2017.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/26/2017] [Accepted: 11/05/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with multiple functional somatic syndromes show markedly reduced functioning and numerous somatic symptoms that cannot be explained by conventionally-defined physical disease. Whilst the comorbidity of functional somatic syndromes with mental disorders is well-known, knowledge about physical comorbidity and mortality is scarce. AIM To compare number of physical diseases between patients with multiple functional somatic syndromes (operationalized as multi-organ bodily distress syndrome) and the general population with regard to: 1) All conventionally-defined physical diseases, and 2) Severe mortality-associated physical diseases. MATERIALS AND METHODS Patients with multiple functional somatic syndromes (n=239) were compared with age- and gender-matched population-based controls (n=5975). The number of physical diseases during a four-year period was estimated by means of registered ICD-10 codes in relation to hospital admissions and ambulatory care. We counted individual diagnoses indicating conventionally-defined physical disease based on a previously developed diagnosis sorting algorithm and an additional clinical evaluation, excluding unspecific (symptom) diagnoses and functional somatic syndromes. An updated version of Charlson Comorbidity Index (CCI12) was used to estimate severe, mortality-associated physical diseases. RESULTS Patients with multiple functional somatic syndromes had an increased number of conventionally-defined physical disease compared to controls (Ratio: 2.17, 95% CI: 1.96-2.41). Groups were similar as regards CCI12 (P=0.55). CONCLUSIONS Patients with multiple functional somatic syndromes showed substantial physical comorbidity. Their burden of severe, mortality-associated physical diseases was comparable to the general population. Further research is needed to clarify the nature, clinical significance, and long-term consequences of the comorbid physical diseases.
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Affiliation(s)
- Marie Weinreich Petersen
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark
| | | | - Charlotte Ulrikka Rask
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark; Child and Adolescent Psychiatric Center, Risskov, Aarhus University Hospital, Denmark
| | - Marian Dalgaard Høeg
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark
| | - Eva Ørnbøl
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark
| | - Andreas Schröder
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark.
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The MELD-Plus: A generalizable prediction risk score in cirrhosis. PLoS One 2017; 12:e0186301. [PMID: 29069090 PMCID: PMC5656314 DOI: 10.1371/journal.pone.0186301] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/28/2017] [Indexed: 02/07/2023] Open
Abstract
Background and aims Accurate assessment of the risk of mortality following a cirrhosis-related admission can enable health-care providers to identify high-risk patients and modify treatment plans to decrease the risk of mortality. Methods We developed a post-discharge mortality prediction model for patients with a cirrhosis-related admission using a population of 314,292 patients who received care either at Massachusetts General Hospital (MGH) or Brigham and Women’s Hospital (BWH) between 1992 and 2010. We extracted 68 variables from the electronic medical records (EMRs), including demographics, laboratory values, diagnosis codes, and medications. We then used a regularized logistic regression to select the most informative variables and created a risk score that comprises the selected variables. To evaluate the potential for generalizability of our score, we applied it on all cirrhosis-related admissions between 2010 and 2015 at an independent EMR data source of more than 18 million patients, pooled from different health-care systems with EMRs. We calculated the areas under the receiver operating characteristic curves (AUROCs) to assess prediction performance. Results We identified 4,781 cirrhosis-related admissions at MGH/BWH hospitals, of which 778 resulted in death within 90 days of discharge. Nine variables were the most effective predictors for 90-day mortality, and these included all MELD-Na’s components, as well as albumin, total cholesterol, white blood cell count, age, and length of stay. Applying our nine-variable risk score (denoted as “MELD-Plus”) resulted in an improvement over MELD and MELD-Na scores in several prediction models. On the MGH/BWH 90-day model, MELD-Plus improved the performance of MELD-Na by 11.4% (0.78 [95% CI, 0.75–0.81] versus 0.70 [95% CI, 0.66–0.73]). In the MGH/BWH approximate 1-year model, MELD-Plus improved the performance of MELD-Na by 8.3% (0.78 [95% CI, 0.76–0.79] versus 0.72 [95% CI, 0.71–0.73]). Performance improvement was similar when the novel MELD-Plus risk score was applied to an independent database; when considering 24,042 cirrhosis-related admissions, MELD-Plus improved the performance of MELD-Na by 16.9% (0.69 [95% CI, 0.69–0.70] versus 0.59 [95% CI, 0.58–0.60]). Conclusions We developed a new risk score, MELD-Plus that accurately stratifies the short-term mortality of patients with established cirrhosis, following a hospital admission. Our findings demonstrate that using a small set of easily accessible structured variables can help identify novel predictors of outcomes in cirrhosis patients and improve the performance of widely used traditional risk scores.
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Weeda ER, Nicoll BS, Coleman CI, Sharovetskaya A, Baker WL. Association between weekend admission and mortality for upper gastrointestinal hemorrhage: an observational study and meta-analysis. Intern Emerg Med 2017; 12:163-169. [PMID: 27534406 DOI: 10.1007/s11739-016-1522-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/09/2016] [Indexed: 01/18/2023]
Abstract
Higher in-hospital mortality for weekend vs. weekday admissions has been described. We performed a retrospective study and accompanying meta-analysis to examine the association between weekend admission for upper gastrointestinal hemorrhage (UGIH) and in-hospital mortality. We identified adult admissions to United States (US) hospitals for acute variceal and nonvariceal UGIH between 1/2010 and 12/2012 from the National Inpatient Sample (NIS). We used multivariable logistic regression to compare the odds of in-hospital mortality (adjusting for hospital- and patient-level factors) for weekend vs. weekday admissions. For our meta-analysis, we searched MEDLINE and SCOPUS to identify NIS studies. Using cumulative meta-analysis, we calculated the adjusted odds ratio (aOR) of in-hospital mortality for variceal and nonvariceal UGIH weekend admission. From 2010 to 2012, we identified 119,353 admissions for UGIH. After multivariable adjustment, there was no difference in the odds of mortality for weekend admissions with variceal (aOR 1.00; 95 % CI 0.81-1.23) or nonvariceal UGIH (aOR 1.10; 95 % CI 0.99-1.22); although, a decreased use of endoscopy in weekend admissions for all-cause UGIH (adjusted hazard ratio 0.91; 95 % CI 0.89-0.92) was observed. Meta-analysis of five studies (including our own) shows no association between weekend admission and mortality for variceal UGIH (aOR 1.02; 95 % CI 0.86-1.21). Weekend admission for nonvariceal UGIH is associated with an increased odds of mortality (aOR 1.09; 95 % CI 1.04-1.15). Weekend admission for UGIH is not associated with a higher odds of in-hospital mortality in our observational study. However, we observed a 9.0 % increase in nonvariceal UGIH mortality for weekend admissions in our meta-analysis.
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Affiliation(s)
- Erin Renae Weeda
- University of Connecticut School of Pharmacy, 69 N. Eagleville Rd, Unit 3092, Storrs, CT, 06269, USA
| | - Brandon Scott Nicoll
- University of Connecticut School of Pharmacy, 69 N. Eagleville Rd, Unit 3092, Storrs, CT, 06269, USA
| | - Craig Ian Coleman
- University of Connecticut School of Pharmacy, 69 N. Eagleville Rd, Unit 3092, Storrs, CT, 06269, USA
| | | | - William Leslie Baker
- University of Connecticut School of Pharmacy, 69 N. Eagleville Rd, Unit 3092, Storrs, CT, 06269, USA.
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Caplan DJ, Ghazal TS, Cowen HJ, Oliveira DC. Dental status as a predictor of mortality among nursing facility residents in eastern Iowa. Gerodontology 2017; 34:257-263. [PMID: 28211101 DOI: 10.1111/ger.12260] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study aimed to evaluate dental status (ie, number of teeth and presence of removable dental prostheses) as a predictor of all-cause mortality among nursing facility residents. BACKGROUND Edentulism has been associated with poorer health outcomes in geriatric populations. MATERIALS AND METHODS Between March 2006 and June 2008, oral health screening examinations were completed for 584 residents of 10 nursing facilities in four eastern Iowa counties. In September 2013, demographic, general and oral health information was obtained from the screening forms and linked with Iowa state death certificate data. The study outcome (time to death) was defined as the number of days between the screening examination and death. Univariate and bivariate distributions were assessed, and multivariable Cox proportional hazards regression models were generated to arrive at factors associated with time to death. RESULTS A total of 535 residents were eligible for data analysis. Age at screening ranged from 60-103 years (mean=85.2), 70% were female, and 33% were edentulous. By September 2013, 468 (87.5%) had died, with a median time to death among these individuals of 2.0 years. The final multivariable Cox model included data from 393 (73.4%) of the residents; statistically significant relationships were observed between time to death and dental status, age, sex, cooperativeness with care providers and renal disease. CONCLUSIONS Dental status remained strongly associated with time to death even after controlling for other important demographic and health-related factors.
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Affiliation(s)
- Daniel J Caplan
- Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa, Iowa City, Iowa, USA
| | - Tariq S Ghazal
- Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa, Iowa City, Iowa, USA
| | - Howard J Cowen
- Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa, Iowa City, Iowa, USA
| | - Deise C Oliveira
- Department of Restorative Dentistry, School of Dentistry, University of Detroit Mercy, Detroit, MI, USA
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Xu Y, Li N, Lu M, Dixon E, Myers RP, Jolley RJ, Quan H. Comparison of risk adjustment methods in patients with liver disease using electronic medical record data. BMC Gastroenterol 2017; 17:5. [PMID: 28061757 PMCID: PMC5219741 DOI: 10.1186/s12876-016-0559-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/08/2016] [Indexed: 12/28/2022] Open
Abstract
Background Risk adjustment is essential for valid comparison of patients’ health outcomes or performances of health care providers. Several risk adjustment methods for liver diseases are commonly used but the optimal approach is unknown. This study aimed to compare the common risk adjustment methods for predicting in-hospital mortality in cirrhosis patients using electronic medical record (EMR) data. Methods The sample was derived from Beijing YouAn hospital between 2010 and 2014. Previously validated EMR extraction methods were applied to define liver disease conditions, Charlson comorbidity index (CCI), Elixhauser comorbidity index (ECI), Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), MELD sodium (MELDNa), and five-variable MELD (5vMELD). The performance of the common risk adjustment models as well as models combining disease severity and comorbidity indexes for predicting in-hospital mortality was compared using c-statistic. Results Of 11,121 cirrhotic patients, 69.9% were males and 15.8% age 65 or older. The c-statistics across compared models ranged from 0.785 to 0.887. All models significantly outperformed the baseline model with age, sex, and admission status (c-statistic: 0.628). The c-statistics for the CCI, ECI, MELDNa, and CTP were 0.808, 0.825, 0.849, and 0.851, respectively. The c-statistic was 0.887 for combination of CTP and ECI, and 0.882 for combination of MELDNa score and ECI. Conclusions The liver disease severity indexes (i.e., CTP and MELDNa score) outperformed the CCI and ECI for predicting in-hospital mortality among cirrhosis patients using Chinese EMRs. Combining liver disease severity and comorbidities indexes could improve the discrimination power of predicting in-hospital mortality.
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Affiliation(s)
- Yuan Xu
- Beijing YouAn Hospital, Capital Medical University, Beijing, China.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Ning Li
- Beijing YouAn Hospital, Capital Medical University, Beijing, China.
| | - Mingshan Lu
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Department of Economics, University of Calgary, Calgary, AB, Canada
| | - Elijah Dixon
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Division of General Surgery, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert P Myers
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rachel J Jolley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Xu Y, Li N, Lu M, Myers RP, Dixon E, Walker R, Sun L, Zhao X, Quan H. Development and validation of method for defining conditions using Chinese electronic medical record. BMC Med Inform Decis Mak 2016; 16:110. [PMID: 27542973 PMCID: PMC4992264 DOI: 10.1186/s12911-016-0348-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 08/05/2016] [Indexed: 01/10/2023] Open
Abstract
Background The adoption of the electronic medical record (EMR) is rapidly growing in China. Constantly evolving, Chinese EMRs contain vast amounts of clinical and financial data, providing tremendous potential for research and policy use; however, they are only partially standardized and contain free text or unstructured data. To utilize the information contained in Chinese EMRs, the development of data extraction methodology is urgently needed. The purpose of this study is to develop and validate methods to extract clinical information from the Chinese EMR for research use. Methods Using 2010 to 2014 EMR data from YouAn Hospital, a large teaching hospital affiliated with Capital Medical University in Beijing, China, we developed extraction methods including 40 EMR definitions for defining 6 liver disease, 5 disease severity conditions, and 29 comorbidities and treatments. We conducted a chart review of 450 randomly selected EMRs. Using physician chart review results as a reference, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to validate each EMR definition. Results The sensitivity of the 6 EMR definitions for liver diseases ranged from 78.9 to 100.0 %, and PPV ranged from 82.1 to 100.0 %. The sensitivity of the 5 definitions on disease severity conditions ranged from 91.0 to 100.0 %, and PPV ranged from 79.2 to 100.0 %. Among the 29 EMR definitions for comorbidities and treatments, 23 had sensitivity over 90.0 % and 25 had PPV over 80.0 %. The specificity and NPV for all 40 EMR definitions were over 90.0 %. Conclusion The extraction method developed is a valid way of extracting information on liver diseases, comorbidities and related treatments from YouAn hospital EMRs. Our method should be modified for application to other Chinese EMR systems, following our framework for extracting conditions. Electronic supplementary material The online version of this article (doi:10.1186/s12911-016-0348-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuan Xu
- Beijing YouAn Hospital, Capital Medical University, 8 Xitoutiao Fengtai, Beijing, 100069, China.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ning Li
- Beijing YouAn Hospital, Capital Medical University, 8 Xitoutiao Fengtai, Beijing, 100069, China.
| | - Mingshan Lu
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Department of Economics, University of Calgary, Calgary, Alberta, Canada
| | - Robert P Myers
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Elijah Dixon
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Division of General Surgery, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robin Walker
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Libo Sun
- Beijing YouAn Hospital, Capital Medical University, 8 Xitoutiao Fengtai, Beijing, 100069, China
| | - Xiaofei Zhao
- Beijing YouAn Hospital, Capital Medical University, 8 Xitoutiao Fengtai, Beijing, 100069, China
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Tapper EB, Halbert B, Mellinger J. Rates of and Reasons for Hospital Readmissions in Patients With Cirrhosis: A Multistate Population-based Cohort Study. Clin Gastroenterol Hepatol 2016; 14:1181-1188.e2. [PMID: 27085758 DOI: 10.1016/j.cgh.2016.04.009] [Citation(s) in RCA: 164] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/02/2016] [Accepted: 04/04/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There have been few population-based studies of the rates of and reasons for readmission to the hospital within 30 days among patients with cirrhosis. METHODS We identified all adult patients with cirrhosis who were admitted in 2011 to hospitals in California, Florida Massachusetts, Mississippi, New York, and Washington (119,722 unique index admissions with cirrhosis). We analyzed data from the State Inpatient Databases, which are longitudinal all-payer databases. Data were linked to the American Hospital Association's national survey for hospital characteristics. Outcomes included readmission to any hospital within 30 and 90 days, and the reasons for readmission. RESULTS The 30- and 90-day rates of readmission were 12.9% and 21.2% overall, with limited variation among states. Among patients with more than 3 complications of cirrhosis, 24.2% were readmitted within 30 days and 35.9% were readmitted within 90 days. The presence of hepatic encephalopathy was most strongly associated with readmission within 30 and 90 days (odds ratio, 1.77 for each). Almost 1 in every 4 readmissions was to a different hospital than the one from which the patient was discharged. Among patients with alcoholic liver disease and a history of a complications of cirrhosis, the 2 most common reasons for readmission were acute complications of cirrhosis (in 41.7%) and substance abuse (in 25.0%). Conversely, the most common reasons for readmission of patients with a history of complications of cirrhosis without alcoholic liver disease were acute complications (in 41.0%) and cancer complications (in 16.2%). CONCLUSIONS A high proportion of patients with cirrhosis are readmitted to the hospital (often to a different hospital) within 30 or 90 days; encephalopathy is most strongly associated with readmission. Reasons for readmission differ based on the cause of liver disease, and there are opportunities for quality improvement.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Brian Halbert
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jessica Mellinger
- Division of Gastroenterology, Department of Medicine, University of Michigan Hospitals, Ann Arbor, Michigan
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Development and Performance of an Algorithm to Estimate the Child-Turcotte-Pugh Score From a National Electronic Healthcare Database. Clin Gastroenterol Hepatol 2015; 13:2333-41.e1-6. [PMID: 26188137 PMCID: PMC4655141 DOI: 10.1016/j.cgh.2015.07.010] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & METHODS The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. The CTP score is a composite of 5 subscores, 3 based on objective clinical laboratory values and 2 subjective variables quantifying the severity of ascites and hepatic encephalopathy. To date, no system to quantify CTP score from administrative databases has been validated. The Veterans Outcomes and Costs Associated with Liver Disease study is a multicenter collaborative study to evaluate the outcomes and costs of hepatocellular carcinoma in the U.S. Veterans Health Administration. We developed and validated an algorithm to calculate electronic CTP (eCTP) scores by using data from the Veterans Health Administration Corporate Data Warehouse. METHODS Multiple algorithms for determining each CTP subscore from International Classification of Diseases version 9, Common Procedural Terminology, pharmacy, and laboratory data were devised and tested in 2 patient cohorts. For each cohort, 6 site investigators (Boston, Bronx, Brooklyn, Philadelphia, Minneapolis, and West Haven VA Medical Centers) were provided cases from which to determine validity of diagnosis, laboratory data, and clinical assessment of ascites and encephalopathy. The optimal algorithm (designated eCTP) was then applied to 30,840 cirrhotic patients alive in the first quarter of 2008 for whom 5-year overall and transplant-free survival data were available. The ability of the eCTP score and other disease severity scores (Charlson-Deyo index, Veterans Aging Cohort Study index, Model for End-Stage Liver Disease score, and Cirrhosis Comorbidity) to predict survival was then assessed by Cox proportional hazards regression. RESULTS Spearman correlations for administrative and investigator validated laboratory data in the HCC and cirrhotic cohorts, respectively, were 0.85 and 0.92 for bilirubin, 0.92 and 0.87 for albumin, and 0.84 and 0.86 for international normalized ratio. In the HCC cohort, the overall eCTP score matched 96% of patients to within 1 point of the chart-validated CTP score (Spearman correlation, 0.81). In the cirrhosis cohort, 98% were matched to within 1 point of their actual CTP score (Spearman, 0.85). When applied to a cohort of 30,840 patients with cirrhosis, each unit change in eCTP was associated with 39% increase in the relative risk of death or transplantation. The Harrell C statistic for the eCTP (0.678) was numerically higher than those for other disease severity indices for predicting 5-year transplant-free survival. Adding other predictive models to the eCTP resulted in minimal differences in its predictive performance. CONCLUSION We developed and validated an algorithm to extrapolate an eCTP score from data in a large administrative database with excellent correlation to actual CTP score on chart review. When applied to an administrative database, this algorithm is a highly useful predictor of survival when compared with multiple other published liver disease severity indices.
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A Comparison of the Charlson and Elixhauser Comorbidity Measures to Predict Inpatient Mortality After Proximal Humerus Fracture. J Orthop Trauma 2015; 29:488-93. [PMID: 26165266 DOI: 10.1097/bot.0000000000000380] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Proximal humerus fractures are very common in infirm elderly patients and are associated with appreciable inpatient mortality. We sought to compare the discriminative ability of the Charlson and Elixhauser comorbidity measures for predicting inpatient mortality after proximal humerus fractures. METHODS Data from the Nationwide Inpatient Sample (2002-2011) were obtained. We constructed 2 main multivariable logistic regression models, with inpatient mortality as the dependent variable and 1 of the 2 comorbidity scores, as well as age and sex, as independent variables. A base model that contained only age and sex was also evaluated. The predictive performance of the Charlson and Elixhauser comorbidity measures was assessed and compared using the area under the receiver operating characteristic curve (AUC) derived from these regression models. RESULTS Elixhauser comorbidity adjustment provided better discrimination of inpatient mortality [AUC = 0.840, 95% confidence interval (CI), 0.828-0.853] than the Charlson model (AUC = 0.786, 95% CI, 0.771-0.801) and the base model without comorbidity adjustment (AUC = 0.722, 95% CI, 0.705-0.740). In terms of relative improvement in predictive ability, the Elixhauser score performed 46% better than the Charlson score. CONCLUSIONS Given that inadequate comorbidity risk adjustment can unfairly penalize hospitals and surgeons that care for a disproportionate share of infirm and sick patients, wider adoption of the Elixhauser measure for mortality prediction after proximal humerus fracture-and perhaps other musculoskeletal injuries-merits to be considered.
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Categorized diagnoses and procedure records in an administrative database improved mortality prediction. J Clin Epidemiol 2015; 68:1028-35. [DOI: 10.1016/j.jclinepi.2014.12.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 11/27/2014] [Accepted: 12/12/2014] [Indexed: 01/20/2023]
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Increasing Volume but Decreasing Mortality of Hospitalized Hepatitis C Patients in the United States, 2005 to 2011. J Clin Gastroenterol 2015; 49:620-7. [PMID: 25203363 DOI: 10.1097/mcg.0000000000000216] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with hepatitis C virus infection often require hospitalization for progressive liver disease and complications, incurring high cost and risk of death. GOALS The aim of our study was to investigate recent trends in the economic burden and outcomes of patients hospitalized for hepatitis C in the United States. STUDY Patients with hepatitis C-associated hospitalization were identified from the Nationwide Inpatient Sample 2005 to 2011. We analyzed the in-hospital mortality, hospital service utilization, demographic, and clinical features of patients. A prognostic model to predict in-hospital survival and death with independent risk factors for mortality was developed. RESULTS A total of 607,279 cases of hepatitis C-associated hospitalization were identified. Over 7 years, the annual hospitalized volume increased by 28.8%. In-hospital mortality declined from 8.2% to 6.4%. Median length of stay (4 d) was unchanged but the inflation-adjusted hospital charges increased by 33.3%. Acute respiratory failure was the greatest independent risk factor for mortality [odds ratio (OR)=7.3; 95% confidence interval (CI), 7.0-7.5], followed by septicemia (OR=4.1; 95% CI, 4.0-4.3), renal failure (OR=3.4; 95% CI, 3.3-3.5), and acute liver failure (OR=2.9; 95% CI, 2.7-3.0). On the basis of the major risk factors for mortality, a risk-adjusted model was developed that could predict the in-hospital outcome of hepatitis C patients with an accurate rate of 89.2%. CONCLUSIONS Despite decreasing in-hospital mortality, both hospital volume and charges related to hepatitis C increased from 2005 to 2011. Use of a risk-adjusted model could help predict mortality and improve outcomes of hepatitis C inpatients.
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Predicting In-Hospital Mortality in Elderly Patients With Cervical Spine Fractures: A Comparison of the Charlson and Elixhauser Comorbidity Measures. Spine (Phila Pa 1976) 2015; 40:809-15. [PMID: 25785957 DOI: 10.1097/brs.0000000000000892] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of nationally representative data collected for the National Hospital Discharge Survey. OBJECTIVE To compare the performance of the Charlson and Elixhauser comorbidity-based measures for predicting in-hospital mortality after cervical spine fractures. SUMMARY OF BACKGROUND DATA Mortality occurring as a consequence of cervical spine fractures is very high in the elderly. The Charlson comorbidity measure has been associated with an increased risk of mortality, but its predictive accuracy has yet to be compared with the more recent and increasingly used Elixhauser measure. METHODS Using the National Hospital Discharge Survey for the years 1990 through 2007, we identified all patients aged 65 years or older hospitalized with a diagnosis of cervical spine fracture. The association of each Charlson and Elixhauser comorbidity with mortality was assessed in bivariate analysis using χ tests. Two main multivariable logistic regression models were constructed, with in-hospital mortality as the dependent variable and 1 of the 2 comorbidity-based measures (as well as age, sex, and year of admission) as independent variables. A base model that included only age, sex, and year of admission was also evaluated. The discriminative ability of the models was quantified using the area under the receiver operating characteristic curve (AUC). RESULTS Among an estimated 111,564 patients admitted for cervical spine fractures, 7.6% died in the hospital. Elixhauser comorbidity adjustment provided better prediction of in-hospital case mortality (AUC = 0.852, 95% confidence interval: 0.848-0.856) than the Charlson model (AUC = 0.823, 95% confidence interval: 0.819-0.828) and the base model with no comorbidities (AUC = 0.785, 95% confidence interval: 0.781-0.790). In terms of relative improvement in predictive ability, the Elixhauser model performed 43% better than the Charlson model. CONCLUSION The Elixhauser comorbidity risk adjustment method performed numerically better than the widely used Charlson measure in predicting in-hospital mortality after cervical spine fractures. LEVEL OF EVIDENCE N/A.
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Risk factors for mortality in patients with alcoholic hepatitis and assessment of prognostic models: A population-based study. Can J Gastroenterol Hepatol 2015; 29:131-8. [PMID: 25855876 PMCID: PMC4399372 DOI: 10.1155/2015/814827] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Severe alcoholic hepatitis (AH) is associated with a substantial risk for short-term mortality. OBJECTIVES To identify prognostic factors and validate well-known prognostic models in a Canadian population of patients hospitalized for AH. METHODS In the present retrospective study, patients hospitalized for AH in Calgary, Alberta, between January 2008 and August 2012 were included. Stepwise logistic regression models identified independent risk factors for 90-day mortality, and the discrimination of prognostic models (Model for End-stage Liver Disease [MELD] and Maddrey discriminant function [DF]) were examined using areas under the ROC curves. RESULTS A total of 122 patients with AH were hospitalized during the study period; the median age was 49 years (interquartile range [IQR] 42 to 55 years) and 60% were men. Median MELD score and Maddrey DF on admission were 21 (IQR 18 to 24) and 45 (IQR 26 to 62), respectively. Seventy-three percent of patients received corticosteroids and⁄or pentoxifylline, and the 90-day mortality was 17%. Independent predictors of mortality included older age, female sex, international normalized ratio, MELD score and Maddrey DF (all P<0.05). For discrimination of 90-day mortality, the areas under the ROC curves of the prognostic models (MELD 0.64; Maddrey DF 0.68) were similar (P>0.05). At optimal cut-offs of ≥22 for MELD score and ≥37 for Maddrey DF, both models excluded death with high certainty (negative predictive values 90% and 96%, respectively). CONCLUSIONS In patients hospitalized for AH, well-known prognostic models can be used to predict 90-day mortality, particularly to identify patients with a low risk for death.
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Mellinger JL, Richardson CR, Mathur AK, Volk ML. Variation among United States hospitals in inpatient mortality for cirrhosis. Clin Gastroenterol Hepatol 2015; 13:577-84; quiz e30. [PMID: 25264271 PMCID: PMC4333025 DOI: 10.1016/j.cgh.2014.09.038] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 09/09/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Little is known about geographic variations in health care for patients with cirrhosis. We studied geographic and hospital-level variations in care of patients with cirrhosis in the United States by using inpatient mortality as an outcome for comparing hospitals. We also aimed to identify features of patients and hospitals associated with lower mortality. METHODS We used the 2009 U.S. Nationwide Inpatient Sample to identify patients with cirrhosis, which were based on the International Classification of Diseases, 9th Revision-Clinical Modification diagnosis codes for cirrhosis or 1 of its complications (ascites, hepatorenal syndrome, upper gastrointestinal bleeding, portal hypertension, or hepatic encephalopathy). Multilevel modeling was performed to measure variance among hospitals. RESULTS There were 102,155 admissions for cirrhosis in 2009, compared with 74,417 in 2003. Overall inpatient mortality was 6.6%. On multivariable-adjusted logistic regression, patients hospitalized in the Midwest had the lowest odds ratio (OR) of inpatient mortality (OR, 0.54; P < .001). Patients who were transferred from other hospitals (OR, 1.49; P < .001) or had hepatic encephalopathy (OR, 1.28; P < .001), upper gastrointestinal bleeding (OR, 1.74; P < .001), or alcoholic liver disease (OR, 1.23; P = .03) had higher odds of inpatient mortality than patients without these features. Those who received liver transplants had substantially lower odds of inpatient mortality (OR, 0.21; P < .001). Multilevel modeling showed that 4% of the variation in mortality could be accounted for at the hospital level (P < .001). Adjusted mortality among hospitals ranged from 1.2% to 14.2%. CONCLUSIONS Inpatient cirrhosis mortality varies considerably among U.S. hospitals. Further research is needed to identify hospital-level and provider-level practices that could be modified to improve outcomes.
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Affiliation(s)
- Jessica L Mellinger
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
| | | | - Amit K Mathur
- Section of Transplantation Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Michael L Volk
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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