A Rapid Decrease in Stroke, Acute Coronary Syndrome, and Corresponding Interventions at 65 United States Hospitals Following Emergence of COVID-19.

Background Following the emergence of coronavirus disease 2019 (COVID-19), early reports suggested a decrease in stroke and acute coronary syndrome (ACS). We sought to provide descriptive statistics for stroke and ACS from a sample of hospitals throughout the United States, comparing data from March 2020 to similar months pre-COVID. Methods We performed a retrospective analysis of 65 academic and community hospitals in the Vizient Clinical Data Base. The primary outcome is monthly count of stroke and ACS, and acute procedures for both, from February and March in 2020 compared to the same months in 2018 and 2019. Results are aggregated for all hospitals and reported by Census Region. Results We identified 51,246 strokes (42,780 ischemic, 8,466 hemorrhagic), 1,043 mechanical thrombectomies (MT), 836 tissue plasminogen activator (tPA) administrations, 36,551 ACS, and 3,925 percutaneous coronary interventions (PCI) for ACS. In February 2020, relative to February 2018 and 2019, hospitalizations with any discharge diagnosis of stroke and ACS increased by 9.8% and 12.1%, respectively, while in March 2020 they decreased 18.5% and 7.5%, relative to March 2018 and 2019. When only including hospitalizations with the primary discharge diagnosis of stroke or ACS, in March 2020 they decreased 17.6% and 25.7%, respectively. In March 2020, tPA decreased 3.3%, MT increased 18.8%, although in February 2020 it had increased 36.8%, and PCI decreased 14.7%. These decreases were observed in all Census regions. Conclusions Following greater recognition of the risks of COVID-19, hospitalizations with stroke and ACS were markedly diminished in a geographically diverse sample of United States hospitals. Because the most likely explanation is that some patients with stroke and ACS did not seek medical care, the underlying reasons for this decrease warrant additional study to inform public health efforts and clinical care during this and future pandemics.

Decreasing Incidence of Skin and Soft-tissue Infections in 86 US Emergency Departments, 2009-2014.

Background: The incidence of skin and soft-tissue infections (SSTIs), for which human immunodeficiency virus (HIV) is a significant risk factor, in United States emergency departments (EDs) increased dramatically after 2000 with the emergence of community-associated methicillin-resistant Staphylococcus aureus. Few studies have examined SSTI incidence among HIV-infected and non-HIV-infected patients in the United States after 2010. Methods: Data were obtained for patient encounters at all academic medical center EDs affiliated with the Vizient clinical data warehouse assigned an SSTI-associated code based on the International Classification of Diseases, Ninth Revision, between 1 January 2009 and 31 December 2014. The rate was calculated per 1000 ED encounters by year and stratified by SSTI, HIV infection, or both, and by age group, race, payer type, and region of care. Poisson regression was used to assess temporal change over the study period. Results: In 2009-2014, a total of 47317 HIV-associated and 820440 SSTI-associated encounters were recorded among 25239781 ED patient encounters. The rate of SSTIs decreased by 8% among all patients and by 14.6%, among those with HIV infection. The SSTI incidence overall decreased from 32.0 to 29.7 per 1000 ED encounters between 2009 and 2014. HIV-infected patients had a significantly higher rate of SSTIs than HIV-uninfected patients (adjusted rate ratio, 1.91; 95% confidence interval, 1.84-1.99). Conclusions: The decline in SSTI incidence in US EDs between 2009 and 2014 is a remarkable epidemiologic shift from the increase in SSTIs after 2000, and further research is necessary to assess reasons for this decrease.

Variation by center and economic burden of readmissions after liver transplantation.

The rate and causes of hospital readmissions after liver transplantation (LT) remain largely unknown in the United States. Adult patients (n = 11,937; 43.1% of all LT cases) undergoing LT from 2007 to 2011 were examined with a linkage of the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases to determine the incidence and risk factors for 30-day readmissions and utilization metrics 90 days after LT. The overall 30-day hospital readmission rate after LT was 37.9%, with half of patients admitted within 7 days after discharge. Readmitted patients had worse overall graft and patient survival with a 2-year follow-up. Multivariate analysis identified risk factors associated with 30-day hospital readmission, including a higher Model for End-Stage Liver Disease score, diabetes at LT, dialysis dependence, a high donor risk index allograft, and discharge to a rehabilitation facility. After adjustments for donor, recipient, and geographic factors in a hierarchical model, we found significant variation in readmission rates among hospitals ranging from 26.3% to 50.8% (odds ratio, 0.53-1.90). In the 90-day analysis after LT, readmissions accounted for $43,785 of added costs in comparison with patients who were not readmitted in the first 90 days. This is the first national report showing that more than one-third of LT recipients are readmitted to their center within 30 days and that readmissions are associated with center variation and increased resource utilization.

Effect of pretransplant diabetes on short-term outcomes after liver transplantation: a national cohort study.

BACKGROUND & AIMS: We sought to analyse the effect of pretransplant diabetes on post-operative outcomes and resource utilization following liver transplantation. METHODS: A retrospective cohort study was designed using a linkage between the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases. We identified 12 442 patients who underwent liver transplantation at 63 centres from 2007-2011 and separated cohorts of patients with diabetes (n = 2971; 24%) and without (n = 9471; 76%) at the time of transplant. We analysed transplant related outcomes and short-term survival. RESULTS: Diabetic recipients were more likely to be male (70% vs 67%), non-white (32% vs 26%), older (age ≥60; 41% vs 28%), and have a higher BMI (29 vs 27; P < 0.001). More diabetic patients were on haemodialysis (10% vs 7%), had cirrhosis caused by NASH (24% vs 9%; P < 0.001), and received liver allografts from older donors (≥ 60 years; 19% vs 15%) with a higher donor risk index (>1.49; 46% vs 42%; P < 0.001). Post-transplant, diabetic recipients had longer hospital length of stay (10 vs 9 days), higher peri-transplant mortality (5% vs 4%) and 30-day readmission rates (41% vs 37%), were less often discharged to home (83% vs 87%; P < 0.05), and had inferior graft and patient survival. Liver transplant was more expensive for type 1 vs type 2 diabetics ($105 078 vs $100 624, P < 0.001). Poorly controlled diabetic recipients were less likely discharged home following transplant (75% vs 82%, P < 0.01). CONCLUSIONS: This national study indicates that pretransplant diabetes is associated with inferior post-operative outcomes and increased resource utilization after liver transplantation.

The status of adult inpatient care by family physicians at US academic medical centers and affiliated teaching hospitals 2003 to 2012: the impact of the hospitalist movement.

BACKGROUND AND OBJECTIVES: Over the past 10--15 years, the number of hospitalists has grown from a few hundred to over 30,000, and hospitalists have assumed a greater proportion of the care of hospitalized patients. No existing studies report on the impact this movement has had on the characteristics of the hospital practice of family physicians in teaching hospitals. To explore this impact we examined the volume and scope of discharges by family physicians at teaching hospitals in 2003 and 2012, the most recent decade of hospitalist growth. We also compared the characteristics of family physicians' hospital practices in 2012 with hospitalists in 2012 to assess for differences in hospital performance. METHODS: We used the University Health Consortium (UHC) Clinical Database to capture adult non-pregnancy-related inpatient discharges in US teaching hospitals by family physicians and hospitalists in 2003 and 2012. We calculated the proportion of inpatient discharges by specialty in all UCH hospitals; did a qualitative comparison of frequent discharge diagnoses; and analyzed length of stay, case mix index, 7- and 30-day readmission rates, and mortality by specialty using UHCs risk adjustment methodology. RESULTS: The proportion of all inpatient discharges by family physicians in UHC hospitals was stable between 2003 and 2012 (2.7% versus 2.6%) though the volume increased. Over the same time, the proportion of discharges attributable to hospitalists increased (0.0% to 13.9%) with a concomitant decrease in proportion of discharges from general medicine (18.4% to 13.9%) and all other specialties (78.9% to 73.2%). Fourteen of the top 20 discharge diagnoses by family physicians from UHC hospitals were the same between 2003 and 2012. Family physicians and hospitalists shared 17 of the top 20 discharge diagnoses in 2012. Length of hospital stay was stable for family medicine across time and lower than that of hospitalists (4.5 versus 5.5 days; P<.001). Seven- and 30-day readmission rates for any cause were lower for hospitalists but there was no difference in either rate when limited to readmission for the same DRG. Hospitalists cared for a somewhat more complex patient mix. CONCLUSIONS: The growth of hospitalists has had little to no impact on the proportion of inpatient discharges in teaching hospitals by family physicians. Quality of care as judged by length of stay, mortality, and readmission rates was comparable between family physicians and hospitals in 2012.

Costs of outpatient thyroid surgery from the University HealthSystem Consortium (UHC) database.

OBJECTIVE: To compare the cost of same-day vs 23-hour observation outpatient thyroidectomy at US academic medical centers. STUDY DESIGN: Cross-sectional analysis of a national database. SETTING: The University HealthSystem Consortium (UHC) data collected from discharge summaries. SUBJECTS AND METHODS: Discharge data were collected from the first quarter of 2009 through the second quarter of 2013. The UHC database, compiled from more than 200 affiliated hospitals, was searched based on diagnosis codes for outpatient thyroid procedures. Cost data, calculated based on reported charges, were collected in addition to demographics. Comparisons were made between same-day vs 23-hour observation based on cost. Additional stratification was performed based on the extent of thyroidectomy. RESULTS: During the study period, 49,936 outpatient thyroidectomies were performed. Overnight observation (63%) was more common than same-day discharge (37%). The overall mean cost of outpatient thyroidectomy was $5617, with a mean cost of same-day surgery of $4642 compared with $6101 for overnight observation (P < .0001). When stratifying by extent of thyroidectomy, the cost of same-day surgery was consistently lower than that for overnight observation. CONCLUSION: Outpatient thyroidectomy is commonly performed in the United States. It is most commonly performed on a 23-hour overnight observation basis. Overnight stay and complications were chief among other factors associated with higher cost, independent of the type of thyroid procedure performed. In appropriately selected patients, same-day thyroidectomy is a safe and cost-effective alternative to overnight observation or inpatient thyroid procedures.

The Analytic Information Warehouse (AIW): a platform for analytics using electronic health record data.

OBJECTIVE: To create an analytics platform for specifying and detecting clinical phenotypes and other derived variables in electronic health record (EHR) data for quality improvement investigations. MATERIALS AND METHODS: We have developed an architecture for an Analytic Information Warehouse (AIW). It supports transforming data represented in different physical schemas into a common data model, specifying derived variables in terms of the common model to enable their reuse, computing derived variables while enforcing invariants and ensuring correctness and consistency of data transformations, long-term curation of derived data, and export of derived data into standard analysis tools. It includes software that implements these features and a computing environment that enables secure high-performance access to and processing of large datasets extracted from EHRs. RESULTS: We have implemented and deployed the architecture in production locally. The software is available as open source. We have used it as part of hospital operations in a project to reduce rates of hospital readmission within 30days. The project examined the association of over 100 derived variables representing disease and co-morbidity phenotypes with readmissions in 5years of data from our institution's clinical data warehouse and the UHC Clinical Database (CDB). The CDB contains administrative data from over 200 hospitals that are in academic medical centers or affiliated with such centers. DISCUSSION AND CONCLUSION: A widely available platform for managing and detecting phenotypes in EHR data could accelerate the use of such data in quality improvement and comparative effectiveness studies.

Aspirin and clopidogrel use in the early postoperative period following on-pump and off-pump coronary artery bypass grafting.

OBJECTIVE: Preoperative use of clopidogrel increases the risk of bleeding, but its postoperative use has not been studied. We studied early postoperative clopidogrel use in on-pump and off-pump coronary artery bypass grafting. METHODS: Data were obtained from the University HealthSystem Consortium database. We conducted a retrospective analysis of data of 15,067 adults who had coronary artery bypass grafting between 2003 and 2006 and received perioperative aspirin alone or in combination with clopidogrel, with the latter administered within 2 days after coronary artery bypass grafting. Logistic regression was used to analyze in-hospital mortality, 30-day readmission, ischemic or thrombotic events, and bleeding events, with propensity score adjustment for clopidogrel treatment. RESULTS: Combined aspirin and clopidogrel were used in 3268 patients (22%). Compared with aspirin alone, aspirin plus clopidogrel was associated with reductions of in-hospital mortality (0.95% vs 1.78%; adjusted odds ratio: 0.50; 95% confidence interval: 0.25, 0.99) and bleeding events (4.19% vs 5.17%; adjusted odds ratio: 0.70; 95% confidence interval: 0.51, 0.97). Ischemic or thrombotic events were not significantly different (1.29% vs 1.53%; adjusted odds ratio, 0.99; 95% confidence interval: 0.59, 1.64). The relative effect of combined treatment did not differ between on-pump and off-pump coronary artery bypass grafting. CONCLUSIONS: Early postoperative clopidogrel combined with aspirin may be safe and beneficial compared with perioperative aspirin treatment alone, in both on-pump and off-pump coronary artery bypass grafting. However, a possibility of selection bias calls for randomized controlled trials to confirm our findings.

Safety of selective serotonin reuptake inhibitor in adults undergoing coronary artery bypass grafting.

Selective serotonin reuptake inhibitors (SSRIs) are commonly used in patients with coronary artery disease and depression, but they have been reported to increase the risk for bleeding. However, data on the short-term outcomes comparing SSRI and non-SSRI antidepressant use after coronary artery bypass grafting (CABG) are limited. A retrospective analysis was conducted of 1,380 adults who received any antidepressants before CABG from 2003 to 2006 at academic medical centers participating in the University HealthSystem Consortium. The primary end point was defined as a composite of in-hospital mortality or any bleeding events, including postprocedural hemorrhage or hematoma, gastrointestinal hemorrhage, and reopening of surgical site. A total of 1,076 adults (78%) received SSRIs. After controlling for propensity of receiving SSRIs compared with non-SSRIs, no significant differences were found in the primary end point (9.4% vs 8.2%, adjusted odds ratio [OR] 1.03, 95% confidence interval [CI] 0.60 to 1.78), any bleeding events (6.5% vs 7.2%, OR 0.93, 95% CI 0.50 to 1.76), or in-hospital mortality (3.1% vs 2.3%, OR 0.88, 95% CI 0.47 to 1.65). There was no increased risk associated with SSRI use when the analysis was restricted to patients who received antiplatelet and anticoagulant therapy for acute coronary syndromes (OR 1.03, 95% CI 0.40 to 2.61) and when examined by age, gender, nonsteroidal anti-inflammatory drug use, and type of CABG (on pump or off pump). In conclusion, compared with non-SSRIs, the preoperative use of SSRIs does not seem to increase the risk for bleeding or in-hospital mortality after CABG.

Racial disparity in the relationship between hospital volume and mortality among patients undergoing coronary artery bypass grafting.

OBJECTIVE: To examine whether the volume-mortality relationship in coronary artery bypass grafting (CABG) differs by race and operative risk. SUMMARY BACKGROUND DATA: In-hospital mortality after CABG is inversely associated with hospital volume. Racial disparities exist in the outcomes of CABG, possibly due to blacks' high operative risk. METHODS: We analyzed 71,949 CABG procedures performed between 2002 and 2005 at 93 academic medical centers participating in the University HealthSystem Consortium. In-hospital mortality was examined across hospital volume categories (very low, <100/yr; low, 100-299/yr; medium, 300-499/yr; and high, > or =500/yr) via logistic regression. RESULTS: In-hospital mortality was 2.0% in whites and 2.8% in blacks. Controlling for patient risk, geographic region, and proportion of African American patients treated at the hospital, the benefit of higher volume was substantial for blacks but only modest for whites (race-by-volume interaction; P = 0.033). Odds ratios of mortality for increasing volume categories (compared with very low volume) were 0.46, 0.37, and 0.47 among blacks but only 0.85, 0.77, and 0.75 among whites. Racial disparities in mortality existed mostly in very low-volume hospitals. The differential volume effect across the 2 racial groups seemed to be primarily driven by regional patterns, as the volume effect was much more pronounced in the South and the Midwest (region by volume interaction; P = 0.033). CONCLUSIONS: Blacks have greater reduction in mortality than whites by undergoing CABG at higher-volume hospitals, regardless of operative risk. Because of limited generalizability, these findings should be confirmed using more representative database.

Venous thromboembolism in elective operations: balancing the choices.

BACKGROUND: Venous thromboembolism (VTE) is a recognized cause of morbidity and mortality in hospitalized patients and is reported to account for 250,000 deaths annually. Recent shifts in prophylaxis administration are occurring among surgical specialty groups after observing a lower rate of VTE among patients undergoing elective operation. We report the incidence of VTE from 3 sources to provide an estimate of the true risk of the complication in elective surgery. METHODS: Data from the Surgical Care Improvement Project (SCIP), University HealthSystem Consortium (UHC), and Kentucky Cabinet for Health and Family Services (CHFS) databases were queried for 2004 for the same operative patient groups. RESULTS: Of 5,285 operations performed within SCIP 2004, the incidences of deep venous thrombosis (DVT) and pulmonary embolus (PE) were 0.4% and 0.3%, respectively, with no reported deaths. Of 966,474 operations recorded in the UHC 2004 data, rates of DVT and PE were 1.2% and 0.5%, respectively. The incidence rates of DVT and PE among 20,563 patients in the CHFS 2004 database were 0.5% and 0.3%, respectively, and included 3 deaths. CONCLUSION: VTE and associated mortality rates are extremely low in these 3 large data sources. We believe patients will benefit from an ongoing assessment of real need and complications of carefully risk-adjusted VTE prophylaxis.