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Purpose: The high ICU bed capacity in the United States (US) allows ICU care of patients requiring invasive mechanical ventilation (IMV), absent public health crisis. The use of IMV without ICU admission (non-ICU) in acute care hospitals in the US and its impact on patients' outcomes were not examined., Methods: A retrospective cohort study was performed using statewide inpatient data in Texas to identify hospitalizations aged ≥18 years receiving IMV in acute care hospitals with ICU care capability during January 2014 through September 2015. Use of non-ICU IMV, patient characteristics, and hospital mortality were examined., Results: Among 136,728 IMV hospitalizations, 4531 (3.3%) were non-ICU. As compared to ICU admissions, non-ICU IMV hospitalizations were younger (age 18-44 years: 24.9% vs. 17.2%), with lower burden of major comorbidities (no major comorbidity: 24.7% vs. 14.5%), and lower occurrence of non-respiratory organ failures (no non-respiratory organ failure: 32.7% vs. 19.8%). Risk-adjusted hospital mortality of non-ICU vs. ICU IMV hospitalizations was 48.7% (95% CI 48.1-49.4) and 29.9% (95% CI 29.8-30.0), respectively., Conclusions: Non-ICU IMV was provided in 1 in 30 IMV hospitalizations in acute care hospitals. Although non-ICU IMV hospitalizations were younger and healthier than those admitted to ICU, their hospital mortality was markedly higher., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To examine the temporal patterns of hospitalizations with diabetic ketoacidosis (DKA) in the pediatric population and their associated fiscal impact., Methods: The Texas Inpatient Public Use Data File was used to identify hospitalizations of state residents aged 1month-19 years with a primary diagnosis of DKA during 2005-2014. Temporal changes of population-adjusted hospitalization rates and hospitalization volumes were examined for the whole cohort and on stratified analyses of sociodemographic attributes. Changes in the aggregate and per-hospitalization charges were assessed overall and on stratified analyses., Results: There were 24,072 DKA hospitalizations during the study period. The population-adjusted hospitalization rate for the whole cohort increased from 31.3 to 35.9 per 100,000 between 2005-2006 and 2013-2014. Hospitalization volume increased by 30.2% over the same period, driven mainly by males, ethnic minorities, those with Medicaid insurance and uninsured patients. The aggregate hospital charges increased from approximately $69 million to $130 million between 2005-2006 and 2013-2014, with 66% of the rise being due to increased per-hospitalization charges., Conclusions: There was progressive rise in pediatric DKA hospitalizations over the last decade, with concurrent near-doubling of the associated fiscal footprint. Marked disparities were noted in the increasing hospitalization burden of DKA, born predominantly by racial and ethnic minorities, as well as by the underinsured and the uninsured. Further studies are needed to identify scalable preventive measures to achieve an equitable reduction of pediatric DKA events., Competing Interests: The authors have declared that no competing interests exist.

Objective: To examine the epidemiology and outcomes of in-hospital cardiopulmonary resuscitation (CPR) among patients with cirrhosis., Methods: We used the Texas Inpatient Public Use Data File to identify hospitalizations aged ≥ 18 years with and without cirrhosis during 2009-2014 and those in each group who have undergone in-hospital CPR. Short-term survival (defined as absence of hospital mortality or discharge to hospice) following in-hospital CPR was examined. Multivariate logistic regression modeling was used to assess the prognostic impact of cirrhosis following in-hospital CPR and predictors of short-term survival among cirrhosis hospitalizations., Results: In-hospital CPR was reported in 2,511 and 51,969 hospitalizations with and without cirrhosis, respectively. The rate of in-hospital CPR (per 1,000 hospitalizations) was 7.6 and 4.0 among hospitalizations with and without cirrhosis, respectively. The corresponding rate of in-hospital CPR among decedents was 10.7% and 13.4%, respectively. Short-term survival following in-hospital CPR among hospitalizations with and without cirrhosis was 14.9% and 27.3%, respectively, and remained unchanged over time on adjusted analyses among the former (p = 0.1753), while increasing among the latter (p = 0.0404). Cirrhosis was associated with lower odds of short-term survival following in-hospital CPR (adjusted odds ratio [aOR] 0.55 [95% CI: 0.49-0.62]). Lack of health insurance (vs. Medicare) (aOR] 0.47 [95% CI: 0.34-0.67]) and sepsis ([aOR] 0.67 [95% CI: 0.53-85]) were associated with lower odds of short-term survival following in-hospital CPR among cirrhosis hospitalizations., Conclusions: The rate of in-hospital CPR was nearly 2-fold higher among hospitalizations with cirrhosis than among those without it, though it was used more selectively among the former. Short-term survival following in-hospital CPR remained markedly lower among cirrhosis hospitalizations, while progressively improving among those without cirrhosis. Strategies to increase access to health insurance and improve early identification and control of infection should be explored in future preventive and interventional efforts., Competing Interests: The author has declared that no competing interests exist.

Background: The short-term outcomes of patients with cystic fibrosis (CF) surviving critical illness were not examined systematically., Objectives: To determine the factors associated with and variation in rates of routine home discharge among ICU-managed adult CF patients., Methods: Predictors of routine home discharge and its hospital-level variation were examined in ICU-managed adults with cystic fibrosis in Texas during 2004-2013., Results: Older age, rural residence, and severity of illness decreased odds of routine home discharge, while hospitalization in facilities accredited as part of the Cystic Fibrosis Foundation Care Center Network nearly doubled the odds of routine home discharge. The median (interquartile) adjusted rate of routine home discharge was 62.0% (31.5-82.5)., Conclusions: The identified determinants of routine home discharge can inform clinical decision-making, while the demonstrated wide variation in adjusted across-hospital rates of routine home discharge of ICU-managed adults with CF can provide benchmark data for future quality improvement efforts., (Published by Elsevier Inc.)

Background: The population-level demand for critical care services among the homeless (H) remains unknown, with only sparse data on the characteristics and outcomes of those managed in the ICU., Methods: The Texas Inpatient Public Use Data File and annual federal reports were used to identify H hospitalizations and annual estimates of the H population between 2007 and 2014. The incidence of ICU admissions in the H population, the characteristics of ICU-managed H, and factors associated with their short-term mortality were examined., Results: Among 52,206 H hospitalizations 15,553 (29.8%) were admitted to ICU. The incidence of ICU admission among state H population rose between 2007 and 2014 from 28.0 to 96.6/1,000 ( p < 0.0001), respectively. Adults aged ≥ 45 years and minorities accounted for 70.2% and 57.6%, respectively, of the growth in volume of ICU admissions. Short-term mortality was 3.2%, with odds of death increased with age, comorbidity burden, and number of failing organs., Conclusions: The demand for critical care services was increasingly high among the H and was contrasted by low short-term mortality among ICU admissions. These findings, coupled with the persistent health disparities among minority H, underscore the need to effectively address homelessness and reduce barriers to longitudinal appropriate prehospital care among the H.

BACKGROUND The demand for critical care services among elderly with dementia outpaces that of their non-dementia elderly counterparts. However, there are scarce data on the corresponding attributes among ICU-managed patients with dementia. MATERIAL AND METHODS We used the Texas Inpatient Public Use Data File to examine temporal trends of the demographics, burden of comorbidities, measures of severity of illness, use of healthcare resources, and short-term outcomes among hospitalizations aged 65 years or older with a reported diagnosis of dementia, who were admitted to ICU (D-ICU hospitalizations) between 2001 and 2010. Average annual percent changes (AAPC) were derived. RESULTS D-ICU hospitalizations (n=276,056) had increasing mean (SD) Charlson comorbidity index [1.7 (1.5) vs. 2.6 (1.9)], with reported organ failure (OF) nearly doubling from 25% to 48.5%, between 2001–2001 and 2009–2010, respectively. Use of life support interventions was infrequent, but rose in parallel with corresponding changes in respiratory and renal failure. Median total hospital charges increased from $26,442 to $36,380 between 2001–2002 and 2009–2010. Routine home discharge declined (–5.2%/year [–6.2%– –4.1%]) with corresponding rising use of home health services (+7.2%/year [4.4–10%]). Rates of discharge to another hospital or a nursing facility remained unchanged, together accounting for 60.4% of discharges of hospital survivors in 2010. Transfers to a long-term acute care hospital increased 9.2%/year (6.9–11.5%). Hospital mortality (7.5%) remained unchanged. CONCLUSIONS Elderly D-ICU hospitalizations have increasing comorbidity burden, with rising severity of illness, and increasing use of health care resources. Though the majority survived hospitalization, most D-ICU hospitalizations were discharged to another facility.