Mental Health Disorders and Emergency Resource Use and Outcomes in Ventricular Assist Device Supported Patients.

2021

2021 Jun 02

1097-6744

<p>There are limited data describing the prevalence of mental health disorders (MHDOs) in patients with ventricular assist devices (VADs), or associations between MHDOs and resource use or outcomes. We used the Nationwide Emergency Department Sample administrative database to analyze 44,041 ED encounters for VAD-supported adults from 2010 to 2017, to assess the relationship between MHDOs and outcomes in this population. MHDO diagnoses were present for 23% of encounters, and were associated with higher charges and rates of admission, but lower mortality.</p>

10.1016/j.ahj.2021.05.018

Am Heart J

34089695

Resource Use and Outcomes of Pediatric Congenital Heart Disease Admissions: 2003 to 2016.

2021

e018286

2021 Feb 06

2047-9980

<p><strong>Background</strong> Children with congenital heart disease (CHD) are known to consume a disproportionate share of resources, yet there are limited data concerning trends in resource use and mortality among admitted children with CHD. We hypothesize that charges in CHD-related admissions increased but that mortality improved over time. <strong>Methods and Results</strong> This study, including patients &lt;18&nbsp;years old with CHD, examined inpatient admissions from the nationally representative Kids' Inpatient Database from 2003 to 2016 in order to assess the frequency, medical complexity, and outcomes of CHD hospital admissions. A total of 859&nbsp;843 admissions of children with CHD were identified. CHD admissions increased by 31.8% from 2003 to 2016, whereas overall pediatric admissions decreased by 13.4%. Compared with non-CHD admissions, those with CHD were more likely to be &lt;1&nbsp;year of age (80.5% versus 63.3%), and to have ≥1 complex chronic condition (39.7% versus 9.3%). For CHD admissions, mortality was higher (2.97% versus 0.31%) and adjusted median charges greater ($48&nbsp;426 [interquartile range (IQR), $11.932-$161&nbsp;048] versus $4697 [IQR, $2551-$12&nbsp;301]) (&lt;0.0001 for all). Among CHD admissions, whereas adjusted median charges increased from $35&nbsp;577 (IQR, $9303-$110&nbsp;439) to $61&nbsp;696 (IQR, $15&nbsp;212-$219&nbsp;237), mortality decreased from 3.2% to 2.7% ( &lt;0.0001). CHD admissions accounted for an increased proportion of all inpatient deaths, from 18.0% in 2003 to 24.5% in 2016. <strong>Conclusions</strong> Children admitted with CHD are 10 times more likely to die than those without CHD and have higher charges. Although the rate of mortality in CHD admissions decreased, children with CHD accounted for an increasing proportion of all pediatric inpatient deaths. Effective resource allocation is critical to optimize outcomes in these high-risk patients.</p>

10.1161/JAHA.120.018286

J Am Heart Assoc

33554612

An Increasing Burden of Disease: Emergency Department Visits Among Patients With Ventricular Assist Devices From 2010 to 2017.

2021

e018035

2021 Feb 05

2047-9980

<p>Background With a growing population of patients supported by ventricular assist devices (VADs) and the improvement in survival of this patient population, understanding the healthcare system burden is critical to improving outcomes. Thus, we sought to examine national estimates of VAD-related emergency department (ED) visits and characterize their demographic, clinical, and outcomes profile. Additionally, we tested the hypotheses that resource use increased and mortality improved over time. Methods and Results This retrospective database analysis uses encounter-level data from the 2010 to 2017 Nationwide Emergency Department Sample. The primary outcome was mortality. From 2010 to 2017, &gt;880&nbsp;million ED visits were evaluated, with 44&nbsp;042 VAD-related ED visits identified. The annual mean visits were 5505 (SD 4258), but increased 16-fold from 2010 to 2017 (824 versus 13&nbsp;155). VAD-related ED visits frequently resulted in admission (72%) and/or death (3.0%). Median inflation-adjusted charges were $25&nbsp;679 (interquartile range, $7450, $63&nbsp;119) per encounter. The most common primary diagnoses were cardiac (22%), and almost 30% of encounters were because of bleeding, stroke, or device complications. From 2010 to 2017, admission and mortality decreased from 82% to 71% and 3.4% to 2.4%, respectively ( for trends &lt;0.001, both). Conclusions We present the first study using national-level data to characterize the growing ED resource use and financial burden of patients supported by VAD. During the past decade, admission and mortality rates decreased but remain substantial; in 2017 ≈1 in every 40 VAD ED encounters resulted in death, making it critical that clinical decision-making be optimized for patients with VAD to maximize good outcomes.</p>

10.1161/JAHA.120.018035

J Am Heart Assoc

33543642

Juvenile Dermatomyositis: A Rare But Treatable Cause of Acute Myocardial Dysfunction.

2020

2020 Jul 22

1536-7355

10.1097/RHU.0000000000001489

J Clin Rheumatol

32701534

The Impact of Syndromic Genetic Disorders on Medical Management and Mortality in Pediatric Hypertrophic Cardiomyopathy Patients.

2020

2020 May 30

1432-1971

<p>Hypertrophic cardiomyopathy (HCM) is a prevalent cardiomyopathy in children, with variable etiologies, phenotypes, and associated syndromic genetic disorders (GD). The spectrum of evaluation in this heterogeneous population has not been well described. We aimed to describe mortality and medical management in the pediatric HCM population, and compare HCM pediatric patients with GD to those without GD. Children (&lt; 18&nbsp;years) with HCM from the claims-based Truven Health Analytics MarketScan Research Database for years 2013-2016 were identified. Outcomes, including patient visits, diagnostic tests, procedures, medications, and mortality, were reported across demographic and clinical characteristics. Multivariable negative binomial, logistic, and survival models were utilized to test the association between those with and without GD by outcomes. 4460 patients were included, with a median age of 11&nbsp;years (IQR 3-16), 61.7% male, 17.7% with GD, and 2.1% who died during the study period. There were 0.36 inpatient admissions per patient-year. Patients with GD were younger [8&nbsp;years (IQR 1-14) vs 12&nbsp;years (IQR 3-16) (p &lt; 0.0001)], had more echocardiograms (1.77 vs 0.93) p &lt; 0.0001; and ambulatory cardiac monitoring per year (0.32 vs 0.24); p = 0.0002. Adjusting for potential confounders including age, other chronic medical conditions, procedures, and heart failure, GD had increased risk of mortality [HR 2.46 (95% CI 1.62, 3.74)], myectomy [HR 1.59 (95% CI 1.08, 2.35)], and more annual admissions [OR 1.36 (CI 1.27, 1.45]. Patients with HCM show higher rates of death, admission, testing, and myectomy when concomitant syndromic genetic disorders are present, suggesting that the disease profile and resource utilization are different from HCM patients without GD.</p>

10.1007/s00246-020-02373-4

Pediatr Cardiol

32474737

A Comparison of Bidirectional Glenn vs. Hemi-Fontan Procedure: An Analysis of the Single Ventricle Reconstruction Trial Public Use Dataset.

2020

2020 May 29

1432-1971

<p>Patients with single ventricle (SV) heart defects have two primary surgical options for superior cavopulmonary connection (SCPC): bidirectional Glenn (BDG) and hemi-Fontan (HF). Outcomes based on type of SCPC have not been assessed in a multi-center cohort. This retrospective cohort study uses the Single Ventricle Reconstruction (SVR) Trial public use dataset. Infants who survived to SCPC were evaluated through 1&nbsp;year of age, based on type of SCPC. The primary outcome was transplant-free survival at 1&nbsp;year. The cohort included 343 patients undergoing SCPC across 15 centers in North America; 250 (73%) underwent the BDG. There was no difference between the groups in pre-SCPC clinical characteristics. Cardiopulmonary bypass times were longer [99&nbsp;min (IQR 76, 126) vs 81&nbsp;min (IQR 59, 116), p &lt; 0.001] and use of deep hypothermic circulatory arrest (DHCA) more prevalent (51% vs 19%, p &lt; 0.001) with HF. Patients who underwent HF had a higher likelihood of experiencing more than one post-operative complication (54% vs 41%, p = 0.05). There were no other differences including the rate of post-operative interventional cardiac catheterizations, length of stay, or survival at discharge, and there was no difference in transplant-free survival out to 1&nbsp;year of age. Mortality after SCPC is low and there is no difference in mortality at 1&nbsp;year of age based on type of SCPC. Differences in support time and post-operative complications support the preferential use of the BDG, but additional longitudinal follow-up is necessary to understand whether these differences have implications for long-term outcomes.</p>

10.1007/s00246-020-02371-6

Pediatr Cardiol

32472151

Comparing Resource Use and Outcomes between Patients with Ventricular Assist Devices and Orthotopic Heart Transplant in the United States from 2006-2014: A Nationally Representative Sample of Emergency Department Visits.

2020

S151

2020 Apr

1557-3117

<p><b>PURPOSE: </b>With advances in mechanical circulatory support and orthotopic heart transplants (OHT) remaining a limited resource, there has been a dramatic increase in Ventricular Assist Device (VAD) implantation. There is minimal data comparing emergency department (ED) resource utilization and outcomes between these populations. We examined national estimates of VAD and OHT-related ED visits and evaluated admissions, resource utilization, and mortality.</p><p><b>METHODS: </b>This study is an epidemiological analysis comparing national estimates of ED visit-level data from the 2006-2014 Nationwide Emergency Department Sample (NEDS) in patients with VADs vs OHT, identified using ICD-9 codes. The primary outcome was death; secondary outcomes included median inflation-adjusted charge and hospital admission. We tested the hypothesis that resource utilization and mortality are higher in ED visits for VAD patients compared to OHT patients.</p><p><b>RESULTS: </b>17,356 VAD-related ED, and 138,133 OHT-related visits were identified. Patients with VADs were more likely to be male (74% vs 70%, p=0.001) and ≥ 65 yo (39% vs 38%, p=0.0004). VADs were more likely to have a primary diagnosis of bleeding (25% vs 2%) and less likely to have acute respiratory disease (6% vs 20%, p<0.0001 for both). VAD-related ED visits had higher rates of inpatient admission or transfer (73% vs 57%) and a higher mortality rate (4.7% vs 1.8%) than patients with OHT (p <0.0001 for all). Moreover, VAD related ED visits had higher median inflation-adjusted charges [$23,862 (IQR $7,129-$58,265) vs $11,364 (IQR $3,001-$31,694)] (p<0.0001).</p><p><b>CONCLUSION: </b>Patients with VADs presenting to the ED represent a population with greater morbidity, mortality and resource utilization compared to OHT. A more developed understanding of those factors that drive mortality and resource use is imperative for improving outcomes in this high-risk population.</p>

10.1016/j.healun.2020.01.1085

J. Heart Lung Transplant.

32464925

Epidemiology of Patients with Ventricular Assist Devices Presenting to the Emergency Room from 2006-2014.

2020

S334

2020 Apr

1557-3117

<p><b>PURPOSE: </b>Data related to the epidemiology and resource utilization of ventricular assist device (VAD) related emergency department (ED) visits are limited. However, an improved understanding of the burden of VADs on the healthcare system is critical to designing interventions that improve outcomes. We examined national estimates of VAD-related ED visits and described medical complexity, admissions, resource utilization, and mortality.</p><p><b>METHODS: </b>This study utilizes data from ED encounter-level data via the 2006-2014 Nationwide Emergency Department Sample (NEDS). ICD-9 codes were used to identify patient-encounters with VADs. Demographic and clinical factors are reported via descriptive statistics. The primary outcome was death; secondary outcomes included median inflation-adjusted charge and hospital admission.</p><p><b>RESULTS: </b>From 2006 to 2014, over 900 million ED visits were evaluated, of which 17,356 (.002%) VAD-related ED visits were identified, for a median of 1,028 (SD 1,489) visits per year. Most VAD ED encounters were represented by patients that were male (74%), ≥ 45 years old (73%), and living in an urban environment (85%). 73% of VAD related ED visits resulted in inpatient admission and the median inflation-adjusted charge was $23,862 (IQR 7,129; 58,265) per visit. Mortality, either in the ED or during an associated admission, was 4.7%. The most common primary diagnoses were cardiac (32%) followed by bleeding (25%) and infection (18%). More than half of the encounters were with patients with ≥1 chronic medical condition, with diabetes (34%) and hypertension (31%) the most prevalent.</p><p><b>CONCLUSION: </b>This is the first study to use national level data to describe the clinical characteristics and outcomes of patients with VADs who present to the ED. With nearly 1 in 20 VAD ED encounters resulting in death, strategies to reduce mortality are urgently needed.</p>

10.1016/j.healun.2020.01.362

J. Heart Lung Transplant.

32465439

Age-Dependent Emergency Department Resource Utilization in Patients with a Ventricular Assist Device.

2020

S465

2020 Apr

1557-3117

<p><b>PURPOSE: </b>There are minimal data on emergency department (ED) resource utilization for pediatric patients with ventricular assist devices (VADs), and it is unclear if adult data can be extrapolated to children.</p><p><b>METHODS: </b>This analysis of national estimates of ED-visit level encounters uses the Nationwide Emergency Department Sample (NEDS). Patients from 2006 to 2014 with VADs were identified using ICD-9 codes and categorized as pediatric (≤18y), young adult (19-44y), middle adult (45-64y) and older adult (≥65y). The primary outcome was death; secondary outcomes included median inflation adjusted charge, admission/transfer rate, and primary encounter diagnoses.</p><p><b>RESULTS: </b>Over the 9 years studied, a total of 254 (95% CI 190-318) pediatric, 3,003 (95% CI 2424-3582) young adult, 7,590 (95% CI 6220-8961) middle adult, and 6,857 (95% CI 5604-8110) older adult ED encounters were identified. Compared to all other age groups, the pediatric VAD ED encounters were more likely to occur at a non-teaching or non-metropolitan ED, to have private insurance as a primary payer, and have a higher proportion of female patients (p ≤ 0.0003 for all). The two most frequent primary encounter diagnoses in pediatric patients were acute gastrointestinal (19%) and respiratory complaints (14%), both of which were uncommon in all adult age groups (p < 0.0001). Admission/transfer rate and charges were significantly lower for pediatric VAD ED encounters (p < 0.0001 for both, Figure). In contrast, overall inpatient and ED mortality did not differ (1.7% vs. 2.3% to 5.3%, p > 0.2 for all).</p><p><b>CONCLUSION: </b>In this study evaluating ED resource utilization of VAD patients, pediatric patients had much lower admission rate and charges compared to their adult counterparts-likely reflecting generally lower acuity complaints or potentially less medical complexity. Still, high mortality rates across all ages highlights the ubiquitous fragility of patients with VADs presenting to the ED and the need for strategies to reduce morbidity and mortality.</p>

10.1016/j.healun.2020.01.318

J. Heart Lung Transplant.

32465817

Emergency Department Visits by Children With Congenital Heart Disease.

2018

1817-1825

2018 Oct 09

1558-3597

<p><strong>BACKGROUND: </strong>Data related to the epidemiology and resource utilization of congenital heart disease (CHD)-related emergency department (ED) visits in the pediatric population is limited.</p>

<p><strong>OBJECTIVES: </strong>The purpose of this analysis was to describe national estimates of pediatric CHD-related ED visits and evaluate medical complexity, admissions, resource utilization, and mortality.</p>

<p><strong>METHODS: </strong>This was an epidemiological analysis of ED visit-level data from the 2006 to 2014 Nationwide Emergency Department Sample. Patients age&nbsp;&lt;18 years with CHD were identified using International Classification of Diseases-9th Revision-Clinical Modification codes. We evaluated time trends using weighted regression and tested the hypothesis that medical complexity, resource utilization, and mortality are higher in CHD patients.</p>

<p><strong>RESULTS: </strong>A total of 420,452 CHD-related ED visits (95% confidence interval [CI]: 416,897 to 422,443 visits) were identified, accounting for 0.17% of all pediatric ED visits. Those with CHD were more likely to be&nbsp;&lt;1 year of age (43% vs. 13%), and to have&nbsp;≥1 complex chronic condition (35% vs. 2%). CHD-related ED visits had higher rates of inpatient admission (46% vs. 4%; adjusted odds ratio: 1.89; 95% CI: 1.85 to 1.93), higher median ED charges ($1,266 [interquartile range (IQR): $701 to $2,093] vs. $741 [IQR: $401 to $1,332]), and a higher mortality rate (1% vs. 0.04%; adjusted odds ratio: 1.25; 95% CI: 1.07 to 1.45). Adjusted median charges for CHD-related ED visits increased from $1,219 (IQR: $673 to $2,138) to $1,630 (IQR: $901 to $2,799), while the mortality rate decreased from 1.13% (95% CI: 0.71% to 1.52%) to 0.75% (95% CI: 0.41% to 1.09%) over the 9 years studied.</p>

<p><strong>CONCLUSIONS: </strong>Children with CHD presenting to the ED represent a medically complex population at increased risk for morbidity, mortality, and resource utilization compared with those without CHD. Over 9 years, charges increased, but the mortality rate improved.</p>

10.1016/j.jacc.2018.07.055

J. Am. Coll. Cardiol.

30286926