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Background: Palliative care addresses a range of needs, from symptom management to providing support to patients with hepatocellular cancer (HCC) and their families throughout the illness. However, research on palliative care in HCC remains limited, particularly during the COVID-19 pandemic. This study investigates the healthcare utilization associated with palliative care referral among patients with HCC. Methods: This is a retrospective cross-sectional analysis conducted using the National Inpatient Sample (NIS) database from 2019 to 2021 among patients with HCC age ≥18 years. Results: Among the 35,220 hospitalizations with HCC as the principal diagnosis, 18.7% received inpatient palliative care referrals. Factors associated with increased palliative care referrals included age ≥65 years, Midwest region, Charlson Comorbidity Index (CCI) score ≥3, and end-of-life care, as reflected by discharge resulting in death. No racial or insurance disparities were observed. Palliative care consultations were associated with lower total hospital costs ($20,573 vs $26,035, <0.0001). A higher prevalence of "do-not-resuscitate" status was also found among patients with palliative care referrals. Conclusion: The study provides an understanding of palliative care utilization across pre-pandemic and pandemic periods. Factors such as advanced age, hospital region, and underlying comorbidities influenced the likelihood of referral, with no discernible racial or insurance disparities identified. Palliative care involvement has also been shown to provide cost-effective supportive care with lower hospital costs. These findings provide invaluable guidance for optimizing the integration of palliative care alongside HCC management., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Goals: Peptic ulcer disease is the most frequent cause of upper gastrointestinal bleeding. We sought to establish the epidemiology and hemostasis success rate of the different treatment modalities in this setting., Methods: Retrospective cohort study using the National Inpatient Sample. Non-elective adult admissions with a principal diagnosis of ulcer bleeding were included. The primary outcome was endoscopic, radiologic and surgical hemostasis success rate. Secondary outcomes were patients' demographics, in-hospital mortality and resource utilization. On subgroup analysis, gastric and duodenal ulcers were studied separately. Confounders were adjusted for using multivariate regression analysis., Results: A total of 136,425 admissions (55% gastric and 45% duodenal ulcers) were included. The mean patient age was 67 years. The majority of patients were males, Caucasians, of lower income and high comorbidity burden. The endoscopic, radiological and surgical therapy and hemostasis success rates were 33.6, 1.4, 0.1, and 95.1%, 89.1 and 66.7%, respectively. The in-hospital mortality rate was 1.9% overall, but 2.4% after successful and 11.1% after failed endoscopic hemostasis, respectively. Duodenal ulcers were associated with lower adjusted odds of successful endoscopic hemostasis, but higher odds of early and multiple endoscopies, endoscopic therapy, overall and successful radiological therapy, in-hospital mortality, longer length of stay and higher total hospitalization charges and costs., Conclusions: The ulcer bleeding endoscopic hemostasis success rate is 95.1%. Rescue therapy is associated with lower hemostasis success and more than a ten-fold increase in mortality rate. Duodenal ulcers are associated with worse treatment outcomes and higher resource utilization compared with gastric ulcers., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: The US Preventive Services Task Force lowered the recommended starting age for colorectal cancer (CRC) screening in average-risk adults from 50 to 45 years. We aimed to estimate the global burden and trends of colorectal cancer in adults aged 20-49 years (early-onset CRC)., Methods: This is an analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019). The GBD 2019 estimation methods were used to describe the incidence, mortality, and disability-adjusted life years (DALYs) of early CRC from 1990 to 2019. Data from 204 countries and geographic areas were available., Results: The global incidence rate of early-onset CRC increased from 4.2/100 000 to 6.7/100 000 from 1990 to 2019. Mortality and DALYs of early-onset CRC also increased. The CRC incidence rate increased faster in younger adults (1.6%) than in adults aged 50-74 years (0.6%) as measured by the annual percentage change. The increase in early-onset CRC incidence was consistently observed in all five socio-demographic index (SDI) regions and 190 out of 204 countries and territories. Middle and high-middle SDI regions had faster annual increases in early-onset CRC, which warrants further attention., Conclusions: The global incidence, mortality, and DALYs of early-onset CRC increased from 1990 to 2019. The increase in early-onset CRC incidence was prevalent worldwide. Several countries were found to have higher incidence rates than the United States or fast increase in early-onset CRC, which warrants further attention., (© 2023 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Goals: We sought to evaluate hospital outcomes of cirrhosis patients with nonvariceal upper gastrointestinal bleeding (NVUGIB)., Background: NVUGIB is common in patients with cirrhosis. However, national outcome studies of these patients are lacking., Study: We utilized the 2014 Nationwide Readmission Database to evaluate NVUGIB in patients with cirrhosis, further stratified as no cirrhosis (NC), compensated cirrhosis (CC), or decompensated cirrhosis (DC). Validated International Classification of Diseases, Ninth Revision, Clinical Modification codes captured diagnoses and interventions. Outcomes included 30-day readmission rates, index admission mortality rates, health care utilization, and predictors of readmission and mortality using multivariable regression analysis., Results: Overall, 13,701 patients with cirrhosis were admitted with NVUGIB. The 30-day readmission rate was 20.8%. Patients with CC were more likely to undergo an esophagogastroduodenoscopy (EGD) within 1 calendar day of admission (74.1%) than patients with DC (67.9%) or NC (69.4%). Patients with DC had longer hospitalizations (4.1 d) and higher costs of care ($11,834). The index admission mortality rate was higher in patients with DC (6.2%) than in patients with CC (1.7%, P <0.001) or NC (1.4%, P <0.001). Predictors of 30-day readmission included performing an EGD >1 calendar day from admission (OR: 1.21; 95% CI, 1.00 to 1.46) and DC (OR: 1.78; 95% CI, 1.54 to 2.06). DC was a predictor of index admission mortality (OR: 3.68; 95% CI, 2.67 to 5.05)., Conclusions: NVUGIB among patients with DC is associated with higher readmission rates, mortality rates, and health care utilization compared with patients with CC and NC. Early EGD is a modifiable variable associated with reduced readmission rates. Early identification of high-risk patients and adherence to guidelines may improve clinical outcomes., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Aim: We aimed to determine the rate of 30-day hospital readmissions of uncomplicated choledocholithiasis and its impact on mortality and health care use in the United States., Methods: Nonelective admissions for adults with uncomplicated choledocholithiasis were selected from the Nationwide Readmission Database 2016-2018. The primary outcome was the all-cause 30-day readmission rate. Secondary outcomes were reasons for readmission, readmission mortality rate, procedures, and resource use (length of stay and total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis., Results: The 30-day rate of readmission was 9.3%. Biliary and pancreatic disorders and postprocedural complications accounted for 36.6% and 10.3% of readmission, respectively. The mortality rate among patients readmitted to the hospital was higher than that for index admissions (2.0% vs. 0.4%, P <0.01). Readmitted patients were less likely to receive endoscopic retrograde cholangiopancreatography (61% vs. 69%, P <0.01) and laparoscopic cholecystectomy (12.5% vs. 26%, P <0.01) during the index admissions. A total of 42,150 hospital days was associated with readmission, and the total health care in-hospital economic burden was $112 million (in costs) and $470 million (in charges). Independent predictors of readmission were male sex, Medicare (compared with private) insurance, higher Elixhauser Comorbidity Index score, no endoscopic retrograde cholangiopancreatography or laparoscopic cholecystectomy, postprocedural complications of the digestive system, hemodynamic or respiratory support, urban hospitals, and lower hospital volume of uncomplicated choledocholithiasis., Conclusions: The uncomplicated choledocholithiasis 30-day readmission rate is 9.3%. Readmission was associated with higher mortality, morbidity, and resource use. Multiple independent predictors of readmission were identified., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background & Aims: Understanding the epidemiology of bleeding and thromboembolism (clotting) in liver cirrhosis provides important data for future studies and policymaking; however, head-to-head comparisons of bleeding and clotting remain limited., Methods: This is a populational retrospective cohort study using the US National Readmission Database of 2018 to compare the incidence and outcomes of bleeding and clotting events in patients with liver cirrhosis. The primary outcomes were the 11-month incidence proportion of bleeding and clotting events., Results: Of 1 304 815 participants, 26 569 had liver cirrhosis (45.0% women, mean age 57.2 [SD, 12.7] years). During the 11-month follow-up, in patients with cirrhosis, for bleeding and clotting events, the incidence proportions was 15.3% and 6.6%; the risk-standardized all-cause mortality rates were 2.4% and 1.0%; the rates of intensive care intervention were 4.1% and 1.9%; the rates of rehabilitation transfer were .2% and .2%; the cumulative length of stays were 45 100 and 23 566 days; total hospital costs were 147 and 84 million US dollars; total hospital charges were 620 and 365 million US dollars. Compared to non-cirrhosis, liver cirrhosis was associated with higher rates of bleeding (adjusted hazard ratio, 3.02 [95% CI, 2.85-3.20]) and portal vein thrombosis (PVT) (18.46 [14.86-22.92]), and slightly lower risks of other non-PVT venous thromboembolic events (.82 [.75-.89])., Conclusions: Bleeding is more common than thromboembolism in patients with liver cirrhosis, causes higher morbidity, mortality and resource utilization. Liver cirrhosis is an independent risk factor for bleeding and PVT, but not non-PVT thromboembolism including venous thromboembolism, acute myocardial infarction and ischemic stroke., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Patients with burn injuries cause significant healthcare economic burden, often utilising extra-hospital resources, caregiving, and specialized care., Methods: We present a retrospective cohort analysis of the hospitalized patients in the USA with a primary diagnosis of burn injury. Opioid dependence was identified using ICD-10 CM codes. The 30-day all-cause readmission rate was the main outcome while secondary outcomes were inhospital mortality rate, resource utilization which included hospital length of stay, total hospitalization costs and charges and surgical procedures for burn injury treatment as well as the most important five principal diagnoses for admission and readmission., Results: Out of 22,348 patients included in the study, 597 had opioid dependence. Older patients (43 years, range: 38.6-47.2 years) as well as males (70.8%) were more likely to be opioid dependent. Opioid dependence was associated with higher 30-day readmission rates (aOR: 1.83, 95% confidence interval (CI): 1.30-2.57, p-value: <0.01), higher total hospitalization costs (aMD: $14,981, CI: $3820-$26,142, p-value: 0.01), total hospitalization charges (aMD: $47,078, CI: -$5093 to $89,063, p-value: 0.03), and a shorter mean length of stay (aMD: 5.13 days, CI: 2.60-7.66, p-value: <0.01). However, patients with and without opioid dependence had similar in-hospital mortality rates (aOR: 0.27, CI: 0.06-1.28, p-value: 0.10)., Conclusion: We are the first to our knowledge to report the association of treatment outcomes and opioid dependence in patients hospitalized at the national level with a burn injury. We show that there were higher 30-day all-cause readmission rates and in-hospital resource utilization among patients with opioid-dependence., (Copyright © 2021 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: The "July effect" refers to the potential of adverse clinical outcomes related to the annual turnover of trainees. We investigated whether this impacts inpatient heart failure (HF) outcomes., Methods: Data from all adults (≥18 years) admitted with a primary diagnosis of HF at US teaching hospitals from the 2012-2014 National Inpatient Sample were analyzed. Non-teaching hospital admissions were excluded. The primary outcome was in-hospital mortality. Secondary metrics included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic and linear regression models were used to adjust for confounders. Admissions were classified into 4 quarters (Q1-Q4), based on the academic calendar. Q1 and Q4 were designated to assess the effect of novice (July effect) versus experienced trainees, respectively., Results: There were 699,675 HF admissions during Q1 and Q4 in the study period. Mean age was 71 ± 15 years and 48% were females. There were 20,270 in-hospital deaths, with no difference between Q1 and Q4; crude odds ratio (OR) 1.00, 95% confidence interval (CI) 0.94-1.07, p = 0.95. After risk adjustment, there was no in-hospital mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, 95% CI 0.89-1.03, p = 0.23. There was no difference in hospital LOS or total cost; 5.8 versus 5.8 days, p = 0.66 and $13,755 versus $13,586, p = 0.46, in Q1 and Q4, respectively., Conclusions: In this nationally representative sample, there was no evidence of a "July effect" on inpatient HF outcomes in the US. This suggests that HF patients should not delay seeking care during trainee transitions at teaching hospitals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background and Aims: We sought to determine the incidence, risk factors, and treatment outcomes of Dieulafoy's lesion of the upper GI tract (UDL) hemorrhage among adult patients in the United States., Methods: UDL and non-Dieulafoy upper GI bleeding (UGIB) were identified from the Nationwide Inpatient Sample and Nationwide Readmission Database using International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System codes. Multivariate logistic (binary) and linear (continuous) regressions were used to model dependent variables., Results: The incidence of UDL hemorrhage was 1.6 of 100,000 persons. Patients with UDL and UGIB who required endoscopic therapeutic intervention had similar in-hospital (adjusted odds ratio [aOR], .77; 95% confidence interval [CI], .42-1.43; P = .41) mortality rates. UDL was associated with more severe systemic illness, including higher rates of mechanical ventilation (aOR, 1.52; 95% CI, 1.07-2.15; P < .05), hypovolemic shock (aOR, 1.50; 95% CI, 1.08-2.08; P < .05), acute kidney injury (aOR, 1.25; 95% CI, 1.02-1.54; P < .05), and multiple endoscopies (aOR, 1.57; 95% CI, 1.28-1.93; P < .05) compared with other UGIB patients who required endoscopic therapeutic intervention. UDL was also associated with higher 30-day all-cause (aOR, 1.23; 95% CI, 1.12-1.35; P < .05) and recurrent bleeding-related (aOR, 1.73; 95% CI, 1.45-2.06; P < .05) readmissions. The rate of successful endoscopic treatment was 96.81%., Conclusions: UDL hemorrhage is an uncommon but highly morbid condition. Current UDL treatment modalities are effective in reducing mortality. Further investigations are warranted to lower recurrent bleeding rates., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Readmission for patients hospitalized with Clostridioides difficile infections (CDIs) carries high morbidity, mortality, and burden on healthcare resources. This study aims to determine if morbid obesity is risk factor for 30-day readmission in patients hospitalized with CDI., Methods: This retrospective cohort study used the 2014 National Readmission Database. Included patients had a principal diagnosis of CDI and excluded if younger than 18 years of age or admitted during the month of December. Readmissions to any hospital for non-trauma diagnoses within 30 days of the index admission were included. The primary outcome was 30-day all cause readmission. Secondary outcomes were (1) in-hospital mortality; (2) morbidity, initiation of dialysis, or total parenteral nutrition; and (3) resource utilization during index admissions., Results: A total of 91,265 subjects were included in this study, 4388 of whom were morbidly obese. Morbid obesity was associated with significantly higher odds of readmission and was associated with higher adjusted mean total hospitalization charges and costs, higher odds of PMV, and acute renal failure requiring dialysis in individuals that develop CDI., Conclusions: Morbid obesity is an independent risk factor for 30-day readmission in patients hospitalized for CDI. Morbidly obese patients admitted for CDI experienced higher morbidity and increased resource utilization.

Splenectomy is one of the treatments of immune thrombocytopenia (ITP) with a high response rate. However, it is an irreversible procedure that can be associated with morbidity in this setting. Our aim was to study the trends of splenectomy in adults with ITP, and the factors associated with splenectomy and resource utilization during these hospitalizations. We used the National (Nationwide) Inpatient Sample (NIS) to identify hospitalizations for adult patients with a principal diagnosis of ITP between 2007 and 2017. The primary outcome was the splenectomy trend. Secondary outcomes were (1) incidence of ITP trend, (2) in-hospital mortality, length of stay, and total hospitalization costs after splenectomy trend, and (3) independent predictors of splenectomy, length of stay, and total hospitalization costs. A total of 36,141 hospitalizations for ITP were included in the study. The splenectomy rate declined over time (16% in 2007 to 8% in 2017, trend p < 0.01) and so did the in-hospital mortality after splenectomy. Of the independent predictors of splenectomy, the strongest was elective admissions (adjusted odds ratio [aOR]: 22.1, 95% confidence interval [CI]:17.8-27.3, P < 0.01), while recent hospitalization year, older age, and Black (compared to Caucasian) race were associated with lower odds of splenectomy. Splenectomy tends to occur during elective admissions in urban medical centers for patients with private insurance. Despite a stable ITP hospitalization rate over the past decade and despite listing splenectomy as a second-line option for management of ITP in major guidelines, splenectomy rates consistently declined over time.

Background: The impact of hospital readmission reduction program (HRRP) on heart failure (HF) outcomes has been debated. Limited data exist regarding trends of HF readmission rates beyond 30 days from all-payer sources. The aim of this study was to investigate temporal trends of 30- and 90-day HF readmissions rates from 2010 to 2017 in patients from all-payer sources., Methods: The National Readmission Database was utilized to identify HF hospitalizations between 2010 and 2017. In the primary analysis, a linear trend in 30-day and 90-day readmissions from 2010 to 2017 was assessed. While in the secondary analysis, a change in aggregated 30- and 90-day all-cause and HF-specific readmissions pre-HRRP penalty phase (2010-2012) and post-HRRP penalties (2013-2017) was compared. Subgroup analyses were performed based on (1) Medicare versus non-Medicare insurance, (2) low versus high HF volume, and (3) HF with reduced versus preserved ejection fraction (heart failure with reduced ejection fraction and heart failure with preserved ejection fraction). Multiple logistic and adjusted linear regression analyses were performed for annual trends., Results: A total of 6 669 313 index HF hospitalizations for 30-day, and 5 077 949 index HF hospitalizations for 90-day readmission, were included. Of these, 1 213 402 (18.2%) encounters had a readmission within 30 days, and 1 585 445 (31.2%) encounters had a readmission within 90 days. Between 2010 and 2017, both 30 and 90 days adjusted HF-specific and all-cause readmissions increased (8.1% to 8.7%, P trend 0.04, and 18.3% to 19.9%, P trend <0.001 for 30-day and 14.8% to 16.0% and 30.9% to 34.6% for 90-day, P trend <0.001 for both, respectively). Readmission rates were higher during the post-HRRP penalty period compared with pre-HRRP penalty phase (all-cause readmission 30 days: 18.6% versus 17.5%, P <0.001, all-cause readmission 90 days: 32.0% versus 29.9%, P <0.001) across all subgroups except among the low-volume hospitals., Conclusions: The rates of adjusted HF-specific and all-cause 30- and 90-day readmissions have increased from 2010 to 2017. Readmissions rates were higher during the HRRP phase across all subgroups except the low-volume hospitals.

Objective: Inferior vena cava filter (IVCF) malfunction can result from penetration, fracture, or migration of the device necessitating retrieval. Endovascular and open retrieval of IVCF have been described in institutional series without comparison. This study examines national hospital admissions for IVCF malfunction and compares the outcomes of open and endovascular retrieval., Methods: The National Inpatient Sample database (2016-2017) was reviewed for admissions with International Classification of Diseases, Tenth Revision (ICD-10) codes specific for IVCF malfunction. All ICD-10 procedural codes were reviewed, and patients were divided based on open or endovascular IVCF retrieval. Patient characteristics, outcomes, and costs of hospitalization were compared between the two groups., Results: There were 665 patients admitted with a diagnosis of IVCF malfunction. Open IVCF retrieval was performed in 100 patients and endovascular removal in 90 patients. Of those undergoing open surgery, 45 patients (45%) required median sternotomy and 55 (55%) required abdominal surgeries. Most patients were white females with a mean age of 54.4 years (range, 49.3-59.6 years) with a history of deep venous thrombosis (55.3%) or pulmonary embolism (31.6%). Most patients with IVCF malfunction were treated in large (81.6%) or urban teaching (94.7%) hospitals situated most commonly in the South (42.1%) and Northeast (29.0%) with no difference in characteristics of the patients or the centers between the two groups. Patients undergoing open IVCF retrieval were more likely to undergo surgery on an elective basis compared with endovascular IVCF retrieval (75.0% vs 11.1%; P < .001). Open IVCF retrieval was associated with a higher likelihood of thromboembolic complication compared with endovascular retrieval (20% vs 0%; P = .04). There was a trend toward higher infectious complications and overall complications with endovascular removal, but this difference did not reach statistical significance. Open retrieval was associated with a mortality of 5.0% compared with no inpatient mortality with endovascular retrieval (P = .33). The mean hospital length of stay was no difference between the two groups. Open retrieval was associated with significantly higher hospital costs than endovascular retrieval ($34,276 vs $19,758; P = .05)., Conclusions: Filter removal for patients with IVCF malfunction is associated with significant morbidity and cost, regardless of modality of retrieval. The introduction of specific ICD-10 codes for IVCF malfunction allows researchers to study these events. The development of effective tools for outpatient retrieval of malfunctioning IVCF could decrease related hospitalization and have potential savings for the healthcare system., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The care of patients who have undergone bariatric surgery is complex and requires a multidisciplinary approach. As such, these patients may be prone to fragmentation of care and differences in healthcare outcomes. We aimed to (1) determine the incidence of fragmentation among patients after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), (2) identify risk factors for readmission, and (3) ascertain whether care fragmentation affects outcomes., Methods: This is a retrospective cohort study using the National Readmission Database 2016. Patients were included if they had primary bariatric surgery during the index hospitalization using appropriate ICD-10 CM codes. Fragmentation of care was defined as a readmission to a different hospital within 90 days of the index admission. Primary outcome was incidence of fragmentation. Secondary outcomes were impact of fragmentation on (1) in-hospital mortality; (2) resource utilization (length of stay (LOS), total hospitalization charges and costs, in-hospital upper endoscopy (EGD), and abdominal imaging studies; and (3) independent predictors of readmission using multivariate regression analysis., Results: A total of 136,536 subjects were included. 90-day readmission demonstrated a prevalence of fragmentation of 21.1%. Type of surgery was an independent predictor of fragmentation, with RYGB leading to increased risk (OR 1.90 [95% confidence interval (CI) 1.61, 2.25]; p-value < 0.0001). RYGB was associated with higher adjusted mean hospitalization costs, which was not explained by increased EGD (OR 0.95, CI 0.68, 1.32) or abdominal imaging (OR 0.52, CI 0.25, 1.06). No differences were found in mortality or LOS., Conclusions: Over 20% of patients following primary bariatric surgery have inpatient readmissions that are fragmented, driven by patients who have undergone RYGB surgery. This may be due to the complexity of this procedure and the need for a multispecialty approach. Additional efforts targeting fragmentation should be made to better coordinate the management of these complex patients and reduce healthcare costs.

Background: Secondary spontaneous pneumothorax (SSP) is defined as a pneumothorax presenting as a complication of underlying lung disease. Due to the high recurrence rate and the possibility of life-threatening complications, same-admission recurrence prophylaxis (SARP) following the first occurrence of SSP is recommended by many experts. The rate of SARP in SSP admissions has not been reported., Research Question: How often were SARP procedures performed in SSP admissions in the United States? How did outcomes differ between SSP admissions with SARP vs those without SARP?, Study Design and Methods: This study used the Nationwide Readmission Database to analyze 71,451,419 inpatient admissions in the United States in 2016 and 2017. SSP admissions with patients aged ≥ 18 years were included, and admissions with documented traumatic or iatrogenic causes of pneumothorax were excluded. Outcomes were compared between SSP admissions with and without SARP. Multivariate logistic analysis was used to model binary-dependent variables., Results: There were 21,838 SSP admissions in 2016 and 2017 (30.56 per 100,000 admissions per year), among which 7,366 (33.73%) received SARP. SARP was associated with lower odds of in-hospital mortality (adjusted OR [aOR], 0.48; 95% CI, 0.34-0.70), 30-day mortality (aOR, 0.52; 95% CI, 0.35-0.77), 90-day mortality (aOR, 0.56; 95% CI, 0.40-0.79), and 1-year mortality (aOR, 0.28; 95% CI, 0.10-0.74). SARP was also associated with lower all-cause readmission at 30 days (aOR, 0.40; 95% CI, 0.40-0.49), 90 days (aOR, 0.47; 95% CI, 0.40-0.55), and 1 year (aOR, 0.46; 95% CI, 0.30-0.68), as well as lower rates of postdischarge pneumothorax recurrence in 30 days (aOR, 0.22; 95% CI, 0.11-0.44), 90 days (aOR, 0.26; 95% CI, 0.20-0.33), and 1 year (aOR, 0.22; 95% CI, 0.11-0.44)., Interpretation: The rate of SARP in SSP admissions was 33.73% in the United States in 2016 and 2017. SARP was associated with lower mortality, all-cause readmission, and pneumothorax recurrence in SSP admissions., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Reduction of early hospital readmissions is a declared goal in the United States economic and quality improvement agenda. A retrospective study was performed using the Nationwide Readmissions Database from 2010 to 2014. Our primary aim was to study the rate of early readmissions and its predictors in liver transplant recipients (LTRs). Our secondary aims were to determine the trends of LT, reasons for readmission, costs and predictors of calendar year mortality. Multivariable logistic regression and Cox proportional hazards models were utilized. The 30-day readmission rate was 30.6% among a total of 25,054 LTRs. Trends of LT were observed to be increased in patients > 65 years (11.7-17.8%, p < 0.001) and decreased in 40-64 years (78.0-73.5%, p = 0.001) during study period. The majority of 30-day readmissions were due to post transplant complications, with packed red blood cell transfusions being the most common intervention during readmission. Medicaid or Medicare insurance, surgery at low and medium volume centers, infections, hemodialysis, liver biopsy, and length of stay > 10 days were the predictors of 30-day readmission. Moreover, number of early readmission, age > 64 years, non-alcoholic cirrhosis, and length of stay > 10 days were significant predictor of calendar year mortality in LTRs. Approximately one third of patients require early admission after LT. Early readmission not only increases burden on healthcare, but is also associated with calendar year mortality. Strategies should be implemented to reduce readmission in patients with high risk of readmission identified in our study.

Background: To study the relationship between race and outcomes of patients with firearm injuries hospitalized in the United States., Methods: The 2016 National Inpatient Sample was used. Patients were included if they had a principal diagnosis of firearm injury. Exclusion criteria were age <16 years and elective admissions. The primary outcome was in-hospital mortality. Secondary outcomes were morbidity (traumatic shock, prolonged mechanical ventilation, acute respiratory distress syndrome [ADRS], and ventilator-associated pneumonia [VAP]), and resource utilization (length of stay and total hospitalization charges and costs)., Results: The sample included 31 335 patients; 52% were Black and 29% were Caucasian. The mean age was 32 years and 88% were male. Black patients had lower odds of mortality (adjusted odds ratio (aOR): 0.41 (95% CI: 0.32-0.53), P < .01). However, compared with Caucasians, Blacks had higher mean total hospitalization charges (adjusted mean difference (aMD) : $14 052 (CI: $1469-$26 635), P = .03) and costs (aMD: $3248 (CI: $654-$5842), P = .01) despite similar mean length of stay (aMD: 0.70 (CI: -0.05-1.45), P = .07). Both racial groups had similar rates of traumatic shock (aOR: 0.91 (0.72-1.15), P = .44), prolonged mechanical ventilation (aOR: 0.82 (0.63-1.09), P = .17), ARDS (aOR: 1.18 (0.45-3.07), P = .74) and VAP (aOR: 1.27 (0.47-3.41), P = .63)., Discussion: Black patients with firearm injuries had a lower adjusted odds of in-hospital mortality compared with other races. However, despite having a similar hospital length of stay and in-hospital morbidity, -Black patients had higher total hospitalization costs and charges.

Background and Aims: Nonvariceal upper GI hemorrhage (NVUGIH) is a feared adverse event after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). We aimed to determine the incidence of NVUGIH after PCI for AMI and its impact on mortality, morbidity, and health care resource utilization over 11 months., Methods: We used the Nationwide Readmission Database 2014. Inclusion criteria were (1) a principal diagnosis of ST or non-ST-elevation myocardial infarction, (2) in-hospital PCI, and (3) admission in January. Exclusion criteria were age less than 18 years and elective admission. The primary outcome was the 11-month incidence of NVUGIH. Secondary outcomes were 11-month mortality rate, prolonged mechanical ventilation, shock, upper endoscopy, length of stay, and total hospitalization costs and charges. Independent risk factors for NVUGIH were identified using multivariate logistic regression analysis., Results: A total of 22,669 patients were included in the study. The mean age was 63.8 years (range, 63.4-64.1 years), and 31.7% of patients were female. The 11-month incidence of NVUGIH was 1.6%. The onset of NVUGIH was associated with an increase in the 11-month mortality rate (adjusted odds ratio, 1.94; 95% confidence interval, 1.01-3.72; P =.04). The upper endoscopy, shock, and prolonged mechanical ventilation rates were 72%, 6.2%, and 1.9%, respectively. In total, 26,532 days were associated with NVUGIH, with a total health care in-hospital economic burden of U.S.$17.6 million. Independent predictors of NVUGIH were female gender, Charlson comorbidity score, and length of stay., Conclusions: The 11-month incidence of NVUGIH among patients who undergo PCI for AMI is 1.6%. NVUGIH has a substantial impact on mortality, morbidity, and in-hospital health care resource utilization., (Copyright © 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests The authors declare that they have no conflict of interest.

Aims: The authors sought to determine the 30-day readmission rate of patients with esophageal variceal hemorrhage (EVH) and its impact on mortality, morbidity, and health care utilization., Background: EVH is a common complication of cirrhosis and leads to substantial morbidity and mortality., Study: The 2014 National Readmission Database was used to examine adult patients with urgent/emergent admissions and a principal diagnosis of EVH. The primary outcome was 30-day readmission. Secondary outcomes were in-hospital and 30-day mortality rate, most common reasons for readmission, readmission mortality rate, morbidity, and resource utilization. Independent risk factors for readmission were identified using multivariate regression analysis., Results: A total of 2003 patients with EVH were included. The mean age was 57 years and 29% of patients were female individuals. The all-cause 30-day readmission rate was 16.6%. EVH was the cause of readmission in only 5% of readmissions. Independent predictors of readmission were age and insurance type. The in-hospital and 30-day mortality rate for index admissions were 7.3% and 8.2%, respectively. For readmitted patients, the mortality rate was 3.9%. Although morbidity was lower during readmissions (prolonged mechanical ventilation: 0.4% vs. 3.5%, P<0.01 and shock: 1.8% vs. 9.9%, P<0.01), the cumulative additional length of stay was substantial at 2054 days with additional total hospitalization charges of US$20 million., Conclusions: The all-cause 30-day readmission rate after EVH is 16.6%, with most patients being readmitted for diagnoses unrelated to EVH. Readmission was associated with a substantial increase in in-hospital mortality and resource utilization. Risk factors for readmission were identified, which can potentially be used to decrease readmission rates.

Background: Both the opioid and gun violence epidemics are recurrent public health issues in the United States. We sought to determine the effect of opioid dependence on gunshot injury treatment outcomes., Materials and Methods: Using the 2016 National Readmission Database, patients were included if they had a principal diagnosis of firearm injury. Opioid dependence was identified using appropriate International Classification of Diseases, 10th Revision, Clinical Modification codes. The primary outcome was 30-day all-cause readmission. Secondary outcomes were in-hospital and 1-year mortality, resource utilization, and most common reasons for admission and readmission. Confounders were adjusted for using multivariate regression analysis., Results: A total of 31,303 patients were included, 695 of whom were opioid dependent. Opioid-dependent patients were more likely to be young (35.1 y, range: 33.4-36.7 y) and male (89.9%) compared with patients without opioid dependence. Opioid dependence was associated with higher 30-day readmission rates (adjusted odds ratio [aOR]: 1.67, 95% confidence interval [CI]: 1.12-2.50, P = 0.01). However, opioid dependence was associated with lower in-hospital (aOR: 0.16, CI: 0.07-0.38, P < 0.01) and 1-year (aOR: 0.15, CI: 0.06-0.38, P < 0.01) mortality, longer mean length of stay (adjusted mean difference [aMD]: 2.09 d, CI: 0.43-3.76, P = 0.03), and total hospitalization costs (aMD: $6,318, CI: $ 257-$12,380, P = 0.04). Both groups had similar total hospitalization charges (aMD: $$10,491, CI: -$12,618-$33,600, P-value = 0.37)., Conclusions: Opioid dependence leads to higher rates of 30-day readmission and resource utilization among patients with firearm injuries. However, the in-hospital and 1-year mortality rates are lower among patients with opioid dependence secondary to lower injury acuity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Lower extremity revascularization for critical limb ischemia (CLI) remains a subject of clinical equipoise. Readmissions and repeat lower extremity revascularization increase the cost of care and decrease the value of initial treatment. This study examines readmissions and repeat inpatient revascularization and major amputation up to 1 year after initial open and endovascular lower extremity revascularization., Methods: The 2014 Nationwide Readmissions Database (NRD) was reviewed. The NRD provides all subsequent readmissions of any hospitalization for the calendar year. A cohort of patients undergoing lower extremity revascularization in January only was selected based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were divided into open and endovascular groups. Readmissions for repeat lower extremity revascularization (RFR) were identified based on procedural codes. Open and endovascular lower extremity revascularization were compared in terms of patient characteristics as well as readmissions, RFR, major amputation, and inpatient mortality at 1 year. Risk-adjusted outcomes accounting for differences in age, gender, income, and Charlson Comorbidity Index (CCI) were derived using regression analysis., Results: There were 1,668 open and 1,410 endovascular lower extremity revascularizations. Patients in the endovascular group were significantly older (P < 0.01), more likely to be women (P < 0.01), and had higher CCI (P < 0.01). Patients undergoing endovascular lower extremity revascularization had significantly higher readmission rate (49 vs. 33.7, P < 0.01) and higher mortality (10.4 vs. 5.3, P < 0.01). Readmitted patients after endovascular lower extremity revascularization had significantly higher mean number of repeat readmissions compared to open lower extremity revascularization (2.49 ± 0.12 vs. 2.13 ± 0.08, P = 0.01). There was no difference in RFR (P = 0.82) or major amputation (P = 0.19). Open revascularization was independently associated with decreased readmission (odds ratio = 0.55 [0.43-0.71]) compared to endovascular. However, there was no significant association between the type of lower extremity revascularization and major amputation or RFR., Conclusions: Endovascular lower extremity revascularization for CLI is performed on older and sicker patients and seems to be associated with increased readmission at 1 year compared to open lower extremity revascularization. Regardless of the initial modality of treatment, patients are likely to undergo at least 1 revascularization during readmissions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Early readmission in patients with decompensated liver cirrhosis leads to an enormous burden on health care use. A retrospective cohort study using the 2013 and 2014 Nationwide Readmission Database (NRD) was conducted. Patients with a diagnoses of cirrhosis and at least one feature of decompensation were included. The primary outcome was to develop a validated risk model for early readmission. Secondary outcomes were to study the 30-day all-cause readmission rate and the most common reasons for readmission. A multivariable logistic regression model was fit to identify predictors of readmissions. Finally, a risk model, the Mumtaz readmission risk score, was developed for prediction of 30-day readmission based on the 2013 NRD and validated on the 2014 NRD. A total of 123,011 patients were included. The 30-day readmission rate was 27%, with 79.6% of patients readmitted with liver-related diagnoses. Age <65 years; Medicare or Medicaid insurance; nonalcoholic etiology of cirrhosis; ≥3 Elixhauser score; presence of hepatic encephalopathy, ascites, variceal bleeding, hepatocellular carcinoma, paracentesis, or hemodialysis; and discharge against medical advice were independent predictors of 30-day readmission. This validated model enabled patients with decompensated cirrhosis to be stratified into groups with low (<20%), medium, (20%-30%), and high (>30%) risk of 30-day readmissions. Conclusion: One third of patients with decompensated cirrhosis are readmitted within 30 days of discharge. The use of a simple risk scoring model with high generalizability, based on demographics, clinical features, and interventions, can bring refinement to the prediction of 30-day readmission in high-risk patients; the Mumtaz readmission risk score highlights the need for targeted interventions in order to decrease rates of readmission within this population., (© 2018 by the American Association for the Study of Liver Diseases.)

Background: The physician workforce at teaching hospitals differs compared to non-teaching hospitals, and data suggest that patient outcomes may also be dissimilar. Delirium is a common, costly disorder among hospitalized patients and approaches to care are not standardized., Objective: This study set out to explore differences in healthcare outcomes between teaching and non-teaching hospitals for patients admitted with delirium., Design: Retrospective cohort analysis., Setting and Participants: We used the 2014 Nationwide Inpatient Sample database. Adult patients (≥18 years of age) hospitalized in acute-care hospitals in the USA with delirium (defined with ICD-9 code) were studied., Main Outcome Measures: The primary outcome was in-hospital all-cause mortality. Secondary outcomes were discharge status and several measures of healthcare resource utilization: length of stay, total hospitalization costs and multiple procedures performed., Results: In 2014, out of 57 460 adult patients admitted to hospitals with delirium, 58.4% were hospitalized at teaching hospitals and the remainder 41.6% at non-teaching hospitals. The in-hospital mortality of delirium patients in teaching hospitals was 1.33% (95% CI 1.08%-1.63%), and 1.26% (95% CI 0.97%-1.63%) in non-teaching hospitals. The mean total hospital costs were $7642 (95% CI 7384-7900) in teaching hospitals, and $6650 (95% CI 6460-6840) in non-teaching hospitals. After adjustment for confounders, total hospitalization costs were statistically significantly different between the hospitals types-with non-teaching providing less expensive care., Conclusions: Patients with delirium admitted to non-teaching hospitals had comparable clinical and process outcomes achieved at lower costs. Further research can be conducted to explore the contextual issues and reasons for these differences in healthcare costs., (© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background/objectives: Gallstones are the leading cause of acute pancreatitis in developed countries. National and international guidelines recommend that a cholecystectomy should be performed during the index hospitalization for acute gallstone pancreatitis. We aimed to delineate the national trends for same-admission cholecystectomy and ERCP for acute gallstone pancreatitis over the last ten years., Methods: We used the 2004, 2009 and 2014 National Inpatient Sample database including patients with a principal diagnosis of acute pancreatitis and a secondary diagnosis of choledocholithiasis or cholelithiasis. Exclusion criteria were age <18 years and elective admission. Primary outcome was the trend in incidence rate of same admission cholecystectomy from 2004 to 2014. The secondary outcomes were: 10-year trend in 1) Incidence of gallstone pancreatitis, 2) proportion of gallstone pancreatitis compared to all other etiologies of acute pancreatitis, 3) incidence rate of same-admission ERCP, 4) length of hospital stay, and 5) total hospitalization costs and charges., Results: The proportion of admissions during which a same-admission cholecystectomy was performed decreased from 48.7% in 2004 to 46.9% in 2009 to 45% in 2014 (trend p < 0.01). During the same time interval, the percentage of admissions during which an ERCP was performed decreased from 25.1% to 18.7% (Trend p < 0.01)., Conclusions: Adherence to the guidelines for same-admission cholecystectomy for patients admitted with acute gallstone pancreatitis have been declining over the past decade. On the other hand, decline in rate of ERCP in patients with acute gallstone pancreatitis and no signs of cholangitis demonstrates adherence to guidelines in this regard., (Copyright © 2019 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background: In patients with diabetes, foot amputations among Black patients have been historically higher compared with White patients. Using the National Inpatient Sample database, we sought to determine if disparities in foot amputations and resource utilization have improved over time. We hypothesized there would be improvements and reduced differences in foot amputations between the two races as quality of care and access to healthcare has improved., Methods and Findings: Patients over 18 years old with a principal diagnosis of diabetic foot complications and secondary diagnosis of Diabetes Mellitus were selected. We compared the primary outcome of foot amputations between Black and White patients. Adjusted rates, odds ratios (aOR) and trends of foot amputations among Black and White patients were studied. Healthcare utilization was measured via length of hospital stay (LOS). Of 262,924 patients, 18% were Black. Following adjustment for confounders, major foot amputations decreased among Whites (1.5% in 2003 to 1.1% in 2014) and Blacks (2.1% in 2003 to 0.9% in 2014). On pooled analysis, Black patients had higher adjusted odds of major foot amputations in 2003-2004 [aOR 1.7; (1.16-2.57), p<0.01]. Disparities in major foot amputations disappeared in 2013-2014 [aOR: 0.92 (0.58-1.44), p = 0.70]. Black patients had declining but persistently longer LOS (adjusted mean difference (aMD): 1.1 days (0.52-1.6) p<0.01 in 2003-2004 and 0.46 days (0.18-0.73) p<0.01 in 2013-2014). The main limitation of the study was that the NIS uses ICD-9 and ICD-10 CM codes, and hence prone to incorrect or missing codes., Conclusions: Major foot amputations declined among Black and White patients hospitalized with Diabetic foot complications between 2003 and 2014. The observed difference for amputations in 2003-2004 was absent by 2013-2014. Future research to determine specific contributors for this reduction in health disparities is needed for ongoing improvements and sustainability., Competing Interests: Marwan Abougergi, MD is the owner of Catalyst Medical Consulting, a large database analysis research consulting firm. He has not received any monetary or non-monetary compensation for his work on the current manuscript This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: We sought to determine treatment outcomes after pancreatoduodenectomy for pancreatic head and uncinate process malignancy and its impact on mortality, morbidity, and resource utilization., Methods: This was a retrospective cohort study using the 2014 Nationwide Readmissions Database. Discharges were included if they had an ICD-9 CM procedure code for pancreatoduodenectomy and any code for malignancy of the pancreas head and uncinate process. Independent predictors of readmission were identified using multivariable Cox regression analysis., Results: A total of 4,445 patients were included. The surgical complication rate was 17.3%, and in-hospital mortality rate was 3%. The 30-day readmission rate was 19.7% with an in-hospital mortality rate of 3.9%. The most common reason for readmission was postoperative infection. The mean length of stay during readmission was 6.50 days, while the mean total hospitalization costs and charges were $15,589 and $52,922, respectively. The number of hospital days associated with readmission was 5,548, with an in-hospital economic burden of $12.9 million (costs) and $43.7 million (charges). Hospital volume and discharge disposition were independent predictors of 30-day readmission., Conclusions: Pancreatoduodenectomy for pancreatic malignancies is still associated with significant morbidity, mortality and 30-day readmission. Reducing readmission can impact mortality, quality of life, and healthcare economic burden in this setting., (© 2019 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Objective: Acute cholangitis (AC) and upper gastrointestinal hemorrhage (UGIH) are common emergencies encountered by gastroenterologists. We aimed to evaluate the impact of UGIH on in-hospital mortality, morbidity and resource utilization among patients with AC., Patients and Methods: Adult admissions with a principal diagnosis of AC were selected from the National Inpatient Sample 2010-2014. The exposure of interest was significant UGIH (requiring red blood cell transfusion). The primary outcome was in-hospital mortality. Secondary outcomes were significant UGIH's incidence, morbidity (shock, prolonged mechanical ventilation and total parenteral nutrition), and resource utilization (length of hospital stay and total hospitalization charges and costs). Confounders were adjusted for using propensity matching and multivariate regression analysis., Results: A total of 50 375 admissions were included in the analysis, 747 of whom developed significant UGIH. After adjusting for confounders, the adjusted odds ratio (aOR) of in-hospital mortality for patients who developed UGIH was 7.1 (95% confidence interval: 2.1-23.9, P<0.01) compared with those who did not. Significant UGIH was associated with substantial increase in morbidity [shock: aOR: 4.1 (2.1-9.3), P<0.01, prolonged mechanical ventilation: aOR: 5.8 (2.2-12.4), P<0.01, total parenteral nutrition: aOR: 4.7 (1.9-10.7), P<0.01], and resource utilization [mean adjusted difference in: length of hospital stay: 7.01 (4.72-9.29), P<0.01 and total hospitalization charges: $81 818 ($58 109-$105 527), P<0.01 and costs: $25 230 ($17 805-$32 653), P<0.01]. Similar results were obtained using multivariate regression analysis., Conclusion: Onset of significant UGIH among patients hospitalized with AC has a detrimental effect on in-hospital mortality, morbidity and resource utilization.

The aim of the study is to investigate effects of morbid obesity on patients hospitalized with diabetic foot ulcers and infections (DFU/Is). This retrospective cohort study of hospitalized adults investigated patients with a principal diagnosis of DFU/Is, and compared outcomes based on weight. The primary outcome was lower limb amputations. Secondary outcomes included in-hospital mortality, morbidity (sepsis and discharge disposition), resource utilization (length of stay [LOS] and total hospitalization charges). Multivariate analyses adjusted for confounders. A total of 31 730 admissions were included; 14% were morbidly obese. Patients with morbid obesity had overall lower rates of amputations (adjusted odds ratio [aOR]: 0.60; 95% confidence interval [CI]: 0.45-0.80). There was no difference in mortality rates between those who were morbidly obese and the non-morbidly obese patients (aOR: 3.89 [95% CI: 0.79-19.30]). Combined data from 2010 to 2014 have found higher odds of sepsis in morbidly obese patients compared with non-morbidly obese patients after adjusting for confounders (aOR: 1.49 [1.09-2.02], P = 0.01). Patients with morbid obesity were less likely to be discharged to home (aOR: 0.82 [95% CI: 0.70-0.95]), had longer LOS (adjusted mean difference [aMD]: 0.47 [95% CI: 0.13-0.81]) and higher hospital charges (aMD: $3205 [95% CI: $3373-$6037]). Despite having lower amputation rates compared to those who are not morbidly obese, patients with morbid obesity hospitalized for DFU/Is succumbed to sepsis more frequently and had less favourable utilization metrics. Specialized care pathways may be needed to enhance the value of care delivered to this high-risk population., (© 2018 World Obesity Federation.)

Goals: To quantify in patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH) the relationship between obesity and mortality, disease severity, treatment modalities, and resource utilization., Background: NVUGIH is the most common gastrointestinal emergency., Study: Adults with a principal diagnosis of NVUGIH were selected from the 2014 National Inpatient Sample. The primary outcome was in-hospital mortality. Secondary outcomes were hemorrhagic shock, prolonged mechanical ventilation (PMV), upper endoscopy [esophagogastroduodenoscopy (EGD)], radiologic treatment, surgery, length of hospital stay (LOS), and total hospitalization costs and charges. Confounders were adjusted for using multivariable regression analyses., Results: In total, 227,480 admissions with NVUGIH were included, 11.70% of whom were obese. Obese and nonobese patients had similar odds of mortality (aOR: 0.88; 95% confidence interval [CI]: 0.69-1.12; P=0.30), EGD within 24 hours of admission (aOR: 0.95; CI: 0.89-1.01; P=0.10), radiologic treatment (aOR: 1.06; CI: 0.82-1.35; P=0.66), and surgery (aOR: 1.27; CI: 0.94-1.70; P=0.11). However, obese patients had higher odds of shock (aOR: 1.30; CI: 1.14-1.49; P<0.01), PMV (aOR: 1.39; CI: 1.18-1.62; P<0.01), undergoing an EGD (aOR: 1.27; CI: 1.16-1.40; P<0.01), needing endoscopic therapy (aOR: 1.18; CI: 1.09-1.27; P<0.01), a longer LOS (0.31 d; CI: 0.16-0.46 d; P<0.01), higher costs ($1075; CI: $636-$1514; P<0.01), and higher charges ($4084; CI: $2060-$6110; P<0.01) compared with nonobese patients., Conclusions: Obesity is not an independent predictor of NVUGIH mortality. However, obesity is associated with a more severe disease course (shock and PMV), higher rates of EGD and endoscopic therapy use, and significant increases in resource utilization (hospital LOS, total hospitalization costs, and charges).

Background and Goals: We examined the interaction between race, insurance, and important outcomes in nonvariceal upper gastrointestinal hemorrhage (NVUGIH)., Study: Adults with NVUGIH were selected from the National Inpatient Sample., Primary Outcome: in-hospital mortality., Secondary Outcomes: treatment modalities [esophagogastroduodenoscopy (EGD), early EGD, and endoscopic or radiologic therapy], and resource utilization (length of hospital stay and total hospitalization charges)., Results: Mortality was similar for Medicare and private insurance [adjusted odds ratios (aOR): 1.15 95% confidence interval (CI) 0.90 to 1.47), P=0.24], but higher for under/uninsured patients [aOR: 1.84 (CI: 1.42 to 2.40), P<0.01]. Compared with Medicare, patients with private insurance had more EGDs [aOR: 1.35 (CI: 1.23 to 1.48), P<0.01], early EGDs [aOR: 1.29 (CI: 1.21 to 1.38), P<0.01], and endoscopic [aOR: 1.19 (CI: 1.11 to 1.27), P<0.01], or radiologic therapy [aOR:1.35 (CI: 1.06 to 1.71), P=0.01]. Patients who were under/uninsured had less EGDs [aOR: 0.84 (CI: 0.76 to 0.91), P<0.01] or endoscopic therapy [aOR: 0.74 (CI: 0.68 to 0.81), P<0.01], but similar odds of early EGD [aOR: 0.95 (CI: 0.88 to 1.02), P=0.13] or radiologic therapy [aOR: 1.01 (CI: 0.75 to 1.37), P=0.75]. Compared with whites, blacks had lower [aOR: 0.73 (CI: 0.58 to 0.93), P=0.01] and Native Americans higher mortality [aOR: 2.60 (CI: 1.57 to 4.13), P<0.01]. Blacks were less likely [aOR: 0.86 (CI: 0.79 to 0.94), P<0.01] and Asians more likely [aOR: 1.24 (CI: 1.05 to 1.47), P=0.01] to have EGDs. Both blacks and Hispanics had lower, whereas Asians had higher early EGD rates. Patients with private insurance had lower total charges [adjusted mean difference: -$2761 (CI: -$4617 to -$906), P<0.01]., Conclusions: Insurance and race have independent effects on NVUGIH mortality, therapeutic modalities used, and resource utilization. Black and under/uninsured patients have the worst outcomes.

Background: Patients with metastatic lung cancer are treated with palliative intent. Aggressive care at the end of life is a marker of poor-quality care. National trends and factors related to aggressive inpatient care at the end of life for these patients have not been evaluated., Methods: Patients with stage IV lung cancer and a terminal hospitalization were identified in the National Inpatient Sample database between 1998 and 2014. Longitudinal analysis was conducted to determine trends in aggressive inpatient care at the end of life and multivariate logistic regression was performed to determine associations with patient and hospital characteristics., Results: A total of 412,946 patients met the inclusion criteria. From 1998 to 2014, the proportion of patients admitted to the intensive care unit (ICU) during the terminal hospitalization increased from 13.3% to 27.9% ( P < .001). The ICU stay translated into a higher mean total cost of care (+$18,461; 95% CI, $17,460 to $19,463). Promisingly, palliative care encounters for terminal hospitalizations also increased during this period from 8.7% to 53.0% ( P < .01) and were correlated with a decrease in aggressive care at the end of life. However, this did not offset the trend in increased ICU use; mean total costs for a terminal hospitalization increased from $14,000 to $19,500, adjusted for inflation. A multivariable model demonstrates variation by patient and hospital characteristics in aggressive care use., Conclusions: Among patients with metastatic lung cancer there has been a substantial increase in ICU use during terminal hospitalizations, resulting in high cost for the health care system.

Objective: To study the relationship between insurance provider and important outcomes among patients with burn injury., Methods: Adults with burn injury were selected from the National Inpatient Sample. The primary outcome was inpatient mortality. Secondary outcomes were morbidity (septic shock and prolonged mechanical ventilation (PMV)), treatment metrics (time to surgery and parenteral or enteral nutrition (P/E-nutrition)) and resource utilization (length of stay (LOS) and total hospitalization costs and charges). Confounders were adjusted for using multivariate regression analysis., Results: Insurance did not affect in-hospital mortality rate. Compared with private insurance, Medicaid was associated with higher septic shock rate (aOR: 2.14 (1.04-4.39), longer LOS (adjusted mean difference (aMD): 2.79 (0.50-5.08) days) and higher costs (aMD: $16,161 ($4789-$27,534) while uninsured patients has shorter LOS (aMD: -2.57 (-4.59--0.55) days), lower charges (aMD: $-37,792 $(-65,550-$-10,034) and costs (aMD: $-8563 ($15,581-$-1544)). Insurance did not affect PMV rates or time to surgery or P/E-nutrition., Conclusions: Primary payer does not affect in-hospital mortality or treatment metrics among patients admitted for burn injury. However, compared with private insurance, Medicaid was associated with both higher morbidity and resource utilization, whereas uninsured patients had lower resource utilization., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Background & Aims: We aimed to determine the rate of hospital readmission within 30 days of non-variceal upper gastrointestinal hemorrhage and its impact on mortality, morbidity, and health care use in the United States., Methods: We performed a retrospective study using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Readmission Database for the year 2014 (data on 14.9 million hospital stays at 2048 hospitals in 22 states). We collected data on hospital readmissions of 203,220 adults who were hospitalized for urgent non-variceal upper gastrointestinal hemorrhage and discharged. The primary outcome was rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity (shock and prolonged mechanical ventilation) and resource use (length of stay and total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis., Results: The 30-day rate of readmission was 13%. Only 18% of readmissions were due to recurrent non-variceal upper gastrointestinal bleeding. The rate of death among patients readmitted to the hospital (4.7%) was higher than that for index admissions (1.9%) (P < .01). A higher proportion of readmitted patients had morbidities requiring prolonged mechanical ventilation (1.5%) compared with index admissions (0.8%) (P < .01). A total of 133,368 hospital days was associated with readmission, and the total health care in-hospital economic burden was $30.3 million (in costs) and $108 million (in charges). Independent predictors of readmission were Medicaid insurance, higher Charlson comorbidity score, lower income, residence in a metropolitan area, hemorrhagic shock, and longer stays in the hospital. Older age, private or no insurance, upper endoscopy, and prolonged mechanical ventilation were associated with lower odds for readmission., Conclusions: In a retrospective study of patients hospitalized for non-variceal upper gastrointestinal hemorrhage, 13% are readmitted to the hospital within 30 days of discharge. Readmission is associated with higher mortality, morbidity, and resource use. Most readmissions are not for recurrent gastrointestinal bleeding., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objective: To study the relationship between day of admission and important outcomes among patients with burn injuries., Methods: The 2014 National Inpatient Sample database was used. Inclusion criterion was a principal diagnosis of burn injury. Exclusion criteria were age <18years, superficial burn, and non-urgent admission. The primary outcome was in-hospital mortality. Secondary outcomes were morbidity (septic shock and prolonged mechanical ventilation), treatment metrics (time to surgery and parenteral or enteral nutrition (P/E-nutrition)) and resource utilization (length of stay (LOS) and total hospitalization charges and costs). Confounders were adjusted for using multivariate regression analysis., Results: A total of 21,665 patients were included, 29% of whom were admitted on weekends. Weekend admission was an independent predictor of mortality only among patients >65years old (adjusted odds ratio (aOR): 2.66 (1.13-4.51), p=0.02). Although rates of septic shock were similar for both groups (aOR): 1.25 (0.74-2.09, p=0.40), weekends were associated with higher odds of prolonged mechanical ventilation (aOR: 1.28 (1.06-1.55), p=0.01). Time to surgery (adjusted mean difference (amDiff): 0.91 (-0.07 to 1.88) days, p=0.07) and time to P/E-nutrition (amDiff: 0.40 (-3.51 to 4.30) days, p=0.80) were similar for both groups. Finally, LOS was longer for weekend admission (amDiff: 1.36 (0.09-2.63) days, p=0.04), but total charges and costs were similar for both groups (amDiff: $16,268 ($-5093-$37,629), p=0.13 and $3275 ($-2337-$8888), p=0.25)., Conclusions: Weekend admission is associated with increased mortality among patients with burn injury >65years old. Weekend admission is also associated with increased morbidity and prolonged length of stay., (Copyright © 2017 Elsevier Ltd and ISBI. All rights reserved.)

Objective: The management of venous thromboembolism (VTE) has evolved during the last decade. This study sheds light on the national trends in hospital admissions, outcomes, and economic burden for VTE., Methods: The National Inpatient Sample (NIS) was reviewed between 2003 and 2013 for hospitalizations for VTE, defined as admissions with a principal diagnosis of deep venous thrombosis (DVT) or pulmonary embolism (PE). Outcomes measured were incidence, inpatient mortality, rates of interventions, hospital length of stay (LOS), and charges. A multivariate analysis was used to identify independent predictors of mortality in patients with VTE., Results: There were 3,368,409 admissions for VTE (54% female; mean age, 62.9 years), at an average of 818 per 100,000 admissions per year. Hospitalizations for PE and VTE significantly increased (P < .01), with no change for DVT (P = .13). Use of catheter-directed thrombolysis increased (0.8% to 2.7%; P < .01), with no significant change in use during the study period (P = .10). The mortality associated with hospitalizations for VTE, PE, and DVT decreased (P < .01). Mean LOS decreased from 5.79 to 4.77 days (P < .01), whereas mean hospital charges increased from $29,755 to $39,171 (P < .01). At the national level, the economic burden of VTE hospitalizations increased from $7.8 billion in 2003 to $12.1 billion in 2013 (P < .01). Older age (odds ratio [OR], 1.03), female gender (OR, 1.05), race (OR, 1.43 for Asian, 1.18 for African American, and 1.18 for Hispanic compared with white), PE (OR, 4.12), and Charlson Comorbidity Index (CCI) ≥3 (OR, 2.75) were all predictors of inpatient mortality (P < .01 for all ORs)., Conclusions: Hospitalizations for VTE increased during the past decade, whereas mortality decreased. Despite a decrease in LOS, there is a rise in economic burden of VTE on the health care system., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Aim: To assess incidence of post-endoscopic retrograde cholangiopancreatography (post-ERCP) pancreatitis in the early (July/August/September) vs the late (April/May/June) academic year and evaluate in-hospital mortality, length of stay (LOS), and total hospitalization charge between these time periods., Methods: This was a retrospective cohort study using the 2012 Nationwide Inpatient Sample (NIS). Patients with International Classification of Diseases, 9 th Revision, Clinical Modification (ICD-9 CM) procedure codes for ERCP were included. Patients were excluded from the study if they had an ICD-9 CM code for a principal diagnosis of acute pancreatitis, if the ERCP was performed before or on the day of admission or if they were admitted to non-teaching hospitals. Post-ERCP pancreatitis was defined as an ICD-9 CM code for a secondary diagnosis of acute pancreatitis in patients who received an ERCP as delineated above. ERCPs performed during the months of July, August and September was compared to those performed in April, May and June in academic hospitals. ERCPs performed at academic hospitals during the early vs late year were compared. Primary outcome was incidence of post-ERCP pancreatitis. Secondary outcomes included in-hospital mortality, length of stay (LOS), and total hospitalization charge. Proportions were compared using fisher's exact test and continuous variables using student t -test. Multivariable regression was performed., Results: From the 36480032 hospitalizations in 2012 in the United States, 6248 were included in the study (3065 in July/August/September and 3183 in April/May/June) in the 2012 academic year. Compared with patients admitted in July/August/September, patients admitted in April/May/June had no statistical difference in all variables including mean age, percent female, Charleston comorbidity index, race, median income, and hospital characteristics including region, bed size, and location. Incidence of post-ERCP pancreatitis in early vs late academic year were not statistically significant (OR = 1.03, 95%CI: 0.71-1.51, P = 0.415). Similarly, the adjusted odds ratio of mortality, LOS, and total hospitalization charge in early compared to late academic year were not statistically significant., Conclusion: Incidence of post-ERCP pancreatitis does not differ at academic institutions depending on the time of year. Similarly, mortality, LOS, and total hospital charge do not demonstrate the existence of a temporal effect, suggesting that trainee level of experience does not impact clinical outcomes in patients undergoing ERCP., Competing Interests: Conflict-of-interest statement: All authors have no conflict of interest related to the manuscript.

Background: Drug-eluting stents (DES) outperform bare-metal stents (BMS) in reducing target vessel revascularization following a percutaneous coronary intervention (PCI). Little is known about the types of stents placed in HIV-positive patients presenting with ST-segment elevation myocardial infarctions (STEMIs)., Methods: We used the 2003-2013 National Inpatient Sample to identify adults of 18 years or older presenting with STEMI. We evaluated differences in stent type placed following STEMIs on the basis of HIV status. Temporal trends in the use of PCI, DES, and BMS were studied on the basis of HIV status., Results: Of 1 695 947 patients with STEMI, 5887 (0.3%) were HIV-positive patients. Following STEMIs, HIV-positive patients were equally likely to have PCI compared with HIV-negative patients [adjusted odds ratio (AOR): 1.04, 95% confidence interval (CI): 0.89-1.21, P=0.63]. However, HIV-positive patients were less likely to have DES (AOR: 0.83, 95% CI: 0.73-0.94, P=0.003) and more likely to have BMS (AOR: 1.26, 95% CI: 1.11-1.45, P=0.001). Over the 11-year period observed, there were increases in PCI following STEMIs in both HIV-positive and HIV-negative patients (all Ptrend<0.001). There were significant increases in the use of DES in HIV-negative patients [adjusted odds ratio (AOR) per year: 1.07, 95% CI: 1.06-1.09, Ptrend<0.001] and significant decreases in the use of BMS (AOR per year: 0.93, 95% CI: 0.92-0.94, Ptrend<0.001). Significant trends showing changed practice patterns in the use of DES and BMS among HIV-positive patients were not observed., Conclusion: Over a decade, there were significant increases in the use of PCI following STEMIs in both HIV-negative and HIV-positive patients. Although HIV-positive patients presenting with STEMIs were as likely as HIV-negative patients to undergo PCI, they were less likely to be treated with DES and more likely to receive BMS. Highlighting these observations will hopefully bring renewed attention to best practices for all STEMI patients.

Aims: To investigate trends in survival to hospital discharge, in-hospital expenditures, and post-acute-care disposition following out-of-hospital cardiac arrest (OHCA) in the United States., Methods: We performed this nationwide serial cross-sectional study using data from the National Inpatient Sample on all patients (age >18years) hospitalized with OHCA between January 1, 1995, and December 31, 2013. Our main outcome measure was survival to hospital discharge. We fitted multivariable regression models with survival, in-hospital expenditures, and post-acute-care disposition as our dependent variables., Results: Of 247,684 patients included in this study, 58.8% were men; mean age was 67 years. Overall trend of survival to discharge was unchanged (P trend =0.56) but a non-significant linear trend increase (49.9% [95% CI, 39.8%-60.0%] in 1995 to 54.0% [95% CI 46.3%-61.8%] in 2013) was noted. Survival improved for patients with VF arrest rhythm but not for those with non-VF arrest rhythm. Increasing age, female gender, non-Caucasian race, high comorbidity burden, non-private primary insurance, non-VF-arrest rhythm and weekend arrest were all negatively associated with neurologically-intact survival. The cost of hospitalization increased from $18,287 ($683) in 2001 to $21,092 ($514) in 2013 at an average annual rate of $261 (P trend <0.001). No change in post-acute discharge disposition was observed except for transfer to a short-term hospital (P trend <0.01)., Conclusions: Overall survival to discharge following out-of-hospital cardiac arrest remained static between 1995 and 2013. Renewed national efforts are needed to warrant better knowledge translation and wider implementation of the best available science in order to improve outcomes., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Helicobacter pylori has been implicated as a risk factor for development of marginal ulceration following gastric bypass, although studies have been small and yielded conflicting results. This study sought to determine the relationship between H. pylori infection and development of marginal ulceration following bariatric surgery in a nationwide analysis., Methods: This was a retrospective cohort study using the 2012 Nationwide Inpatient Sample (NIS) database. Discharges with ICD-9-CM code indicating marginal ulceration and a secondary ICD-9-CM code for bariatric surgery were included. Primary outcome was incidence of marginal ulceration. A stepwise forward selection model was used to build the multivariate logistic regression model based on known risk factors. A P value of 0.05 was considered significant., Results: There were 253,765 patients who met inclusion criteria. Prevalence of marginal ulceration was 3.90%. Of those patients found to have marginal ulceration, 31.20% of patients were H. pylori-positive. Final multivariate regression analysis revealed that H. pylori was the strongest independent predictor of marginal ulceration., Conclusions: H. pylori is an independent predictor of marginal ulceration using a large national database. Preoperative testing for and eradication of H. pylori prior to bariatric surgery may be an important preventive measure to reduce the incidence of ulcer development., (© 2017 The Obesity Society.)

Background: The AIMS65 score and the Glasgow-Blatchford risk score (GBRS) are validated preendoscopic risk scores for upper gastrointestinal hemorrhage (UGIH)., Goals: To compare the 2 scores' performance in predicting important outcomes in UGIH., Study: A prospective cohort study in 2 tertiary referral centers and 1 community teaching hospital. Adults with UGIH were included. The AIMS65 score and GBRS were calculated for each patient. The primary outcome was inpatient mortality. Secondary outcomes were 30-day mortality, in-hospital rebleeding, 30-day rebleeding, length of stay, and a composite endpoint of in-hospital mortality, transfusions, or need for intervention (endoscopic, radiologic, or surgical treatment). The area under the receiver operating characteristic curve (AUROC) was calculated for each score and outcome., Results: A total of 298 patients were enrolled. The AIMS65 score was superior to the GBRS in predicting in-hospital mortality (AUROC, 0.85 vs. 0.66; P<0.01) and length of stay (Somer's D, 0.21 vs. 0.13; P=0.04). The scores were similar in predicting 30-day mortality (AUROC, 0.74 vs. 0.65; P=0.16), in-hospital rebleeding (AUROC, 0.69 vs. 0.62; P=0.19), 30-day rebleeding (AUROC, 0.63 vs. 0.63; P=0.90), and the composite outcome (AUROC, 0.57 vs. 0.59; P=0.49). The optimal cutoffs for predicting in-hospital mortality were an AIMS65 score of 3 and a GBRS score of 10. For predicting rebleeding, the optimal cutoffs were 2 and 10, respectively., Conclusions: The AIMS65 score is superior to the GBRS for predicting in-hospital mortality and hospital length of stay for patients with UGIH. The AIMS65 score and GBRS are similar in predicting 30-day mortality, rebleeding, and a composite endpoint.

Background: Mortality from ST elevation myocardial infarction (STEMI) is decreasing nationwide, but no report to date examined STEMI mortality among patients with cirrhosis., Goals: Determine mortality rates and investigate possible disparities in cardiovascular interventions for patients with and without cirrhosis admitted with STEMI across a decade using a national database., Study: We included all urgent/emergent admissions with STEMI to acute care hospitals across the United States in 1999 and 2009. Exclusion criteria were age less than 18 years or prior liver transplantation. Confounders were accounted for using multivariable regression analyses., Results: A total of 325,857 and 182,491 patients with STEMI were included in 1999 and 2009, respectively, 741 and 541 of whom had cirrhosis, respectively. In-hospital mortality rate was 31% and 11% for patients with and without cirrhosis in 1999, and 17% and 9% in 2009. The adjusted mortality odds ratio was 2.54 (1.52 to 4.24) in 1999 and 1.45 (0.73 to 2.86) in 2009. Stent placement rate was 11% and 26% for patients with and without cirrhosis in 1999, and increased to 47% and 61% in 2009, respectively. Thrombolytic medication injection rate was 3% and 10% for patients with and without cirrhosis in 1999, and 0% and 2% in 2009, respectively. Coronary artery bypass graft surgery rate was 3% and 9% for patients with and without cirrhosis in 1999, and was 6% and 7% in 2009, respectively., Conclusions: STEMI mortality in patients with cirrhosis is higher compared with patients without cirrhosis. However, this mortality difference declined from 1999 to 2009, likely because of higher coronary artery stent utilization for patients with cirrhosis.