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

Venous flow variation predicts preoperative pulmonary venous obstruction in children with total anomalous pulmonary venous connection.

2021

2021 Feb 15

1097-6795

<p><strong>OBJECTIVE: </strong>Identifying preoperative pulmonary venous obstruction in total anomalous pulmonary venous connection (TAPVC) is important to guide treatment-planning and risk prognostication. No standardized echocardiographic definition of obstruction exists in the literature. Definitions based on absolute velocities are affected by technical limitations and variations in pulmonary venous return. We developed a metric to quantify pulmonary venous blood flow variation: pulmonary venous variability index (PVVI). We aimed to demonstrate its accuracy in defining obstruction.</p>

<p><strong>METHODS: </strong>All patients cared for with TAPVC at our institution were identified. Echocardiograms were reviewed, and maximum (V), mean (V), and minimum velocities (V) along the pulmonary venous pathway were measured. PVVI was defined as (V-V)/V. These metrics were compared to pressures measured by cardiac catheterization. Echocardiographic measures were then compared between the patients with and without clinical preoperative obstruction (defined as a need for preoperative intubation, catheter-based intervention, or surgery within one day of diagnosis), as well as pulmonary edema by chest X-ray and markers of lactic acidosis. 137 patients were included with 22 having catheterization pressure recordings.</p>

<p><strong>RESULTS: </strong>Maximum and mean velocity were not different between patients with catheter gradients ≥4 mmHg and &lt;4 mmHg, while PVVI was significantly lower and minimum velocity higher in those with gradients ≥4 mmHg. The composite outcome of preoperative obstruction occurred in 51 patients (37%). Absolute velocities were not different between patients with and without clinical obstruction, while PVVI was significantly lower in patients with obstruction. All metrics except maximum velocity were associated with pulmonary edema; none were associated with blood gas metrics.</p>

<p><strong>CONCLUSIONS: </strong>We developed a novel quantitative metric of pulmonary venous flow, which was superior to traditional echocardiographic metrics. Decreased PVVI was highly associated with elevated gradients measured by catheterization and clinical preoperative obstruction. These results should aid risk assessment and diagnosis preoperatively in patients with TAPVC.</p>

10.1016/j.echo.2021.02.007

J Am Soc Echocardiogr

33600926

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

Variation in treatment of children hospitalized with new-onset systemic juvenile idiopathic arthritis in the United States.

2020

2020 Aug 16

2151-4658

<p><strong>OBJECTIVE: </strong>Increasing evidence supports that early initiation of biologics may dramatically improve disease course and reduce glucocorticoid exposure for children with systemic juvenile idiopathic arthritis (JIA). We characterized variation in the use of first-line biologic and glucocorticoid therapy and identified drivers of variation in children hospitalized with new-onset systemic JIA.</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study of children hospitalized with new-onset systemic JIA from 2008-2019 utilizing a comparative pediatric database from 52 tertiary care children's hospitals. Subjects and treatment receipt were identified using International Classification of Diseases (ICD)-9 and ICD-10 discharge diagnosis codes, pharmacy billing data and clinical transaction classification codes. Mixed-effects logistic regression was used to identify patient and hospital-level factors associated with receipt of glucocorticoids and biologics.</p>

<p><strong>RESULTS: </strong>534 children with new-onset systemic JIA hospitalized during the study period met inclusion criteria. Twenty-nine percent received biologics and 58% received glucocorticoids. Biologic use increased over time (p &lt; 0.001), methotrexate use decreased (p &lt; 0.01), and glucocorticoid use remained unchanged. Biologics and glucocorticoid use varied significantly between hospitals. High annual hospital volume, intensive care unit stay, and later discharge year were significantly associated with biologic exposure. Medium-high and high annual hospital volume were significantly associated with less glucocorticoid exposure.</p>

<p><strong>CONCLUSION: </strong>Despite increasing evidence demonstrating improved outcomes with first-line treatment with biologics, we found significant treatment variation across hospitals with many children not receiving biologics and a persistent high rate of glucocorticoid exposure. These results underscore the need for comparative efficacy studies and improved treatment standardization.</p>

10.1002/acr.24417

Arthritis Care Res (Hoboken)

33242366

Resource Utilization in the First 2 Years Following Operative Correction for Tetralogy of Fallot: Study Using Data From the Optum's De-Identified Clinformatics Data Mart Insurance Claims Database.

2020

e016581

2020 Jul 21

2047-9980

<p><strong>Background</strong> Despite excellent operative survival, correction of tetralogy of Fallot frequently is accompanied by residual lesions that may affect health beyond the incident hospitalization. Measuring resource utilization, specifically cost and length of stay, provides an integrated measure of morbidity not appreciable in traditional outcomes.</p>

<p><strong>Methods and Results</strong> We conducted a retrospective cohort study, using de-identified commercial insurance claims data, of 269 children who underwent operative correction of tetralogy of Fallot from January 2004 to September 2015 with ≥2&nbsp;years of continuous follow-up (1) to describe resource utilization for the incident hospitalization and subsequent 2&nbsp;years, (2) to determine whether prolonged length of stay (&gt;7&nbsp;days) in the incident hospitalization was associated with increased subsequent resource utilization, and (3) to explore whether there was regional variation in resource utilization with both direct comparisons and multivariable models adjusting for known covariates. Subjects with prolonged incident hospitalization length of stay demonstrated greater resource utilization (total cost as well as counts of outpatient visits, hospitalizations, and catheterizations) after hospital discharge (&lt;0.0001 for each), though the number of subsequent operative and transcatheter interventions were not significantly different. Regional differences were observed in the cost of incident hospitalization as well as subsequent hospitalizations, outpatient visits, and the costs associated with each.</p>

<p><strong>Conclusions</strong> This study is the first to report short- and medium-term resource utilization following tetralogy of Fallot operative correction. It also demonstrates that prolonged length of stay in the initial hospitalization is associated with increased subsequent resource utilization. This should motivate research to determine whether these differences are because of modifiable factors.</p>

10.1161/JAHA.120.016581

J Am Heart Assoc

32691679

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

Imaging Intussusception in Children's Hospitals in the United States: Trends, Outcomes, and Costs.

2019

2019 May 14

1558-349X

<p><strong>OBJECTIVE: </strong>To describe imaging utilization, outcomes, and cost in the management of intussusception between 2010 and 2017 in pediatric hospitals in the United States.</p>

<p><strong>METHODS: </strong>All children (under 18 years of age) with a primary diagnosis of intussusception in a large administrative database were identified. Demographics, imaging, and costs were described.</p>

<p><strong>RESULTS: </strong>There were 17,032 children (63.3% boys, 36.7% girls, mean age: 3.2 years) that had 20,655 hospital encounters for intussusception, and 88.5% were &lt;5 years of age. The average length of stay was 2.8 days (median: 1 day), with rates of intensive care unit admission, 3.7%; 90-day readmission, 10.5%; and mortality, 0.2%. The surgical rate was 19.6%, and 93.5% (n&nbsp;= 19,301) of patients underwent imaging: 87.2% (n&nbsp;= 16,822) received ultrasound, 69.1% (n&nbsp;= 13,329) had fluoroscopy, 59% (n&nbsp;= 11,380) had abdominal radiographs, and 8.8% (n&nbsp;= 1,696) had CT. The reduction success rate for fluoroscopy was 77.9%. Surgery was more common in rural patients (26.8% versus 18.7% in urban patients, P &lt; .001). Median encounter costs were $2,675 (interquartile range: $1,637-$5,465). Imaging cost represented a quarter (median $680, interquartile range: $372-1,069) of all costs. Higher costs (median) were associated with longer length of stay (&lt;3 days: $858 versus &gt;3 days: $5,342; use of CT ($4,168 versus $943 in patients without a CT), and surgery ($4,434 versus $860 without surgery).</p>

<p><strong>CONCLUSION: </strong>The management of intussusception is mainly nonsurgical, most frequently involving imaging with ultrasound and fluoroscopy, and resulting in excellent outcomes in the great majority of the cases. Despite playing a central role for diagnosis and management, imaging only represents a fraction of total cost.</p>

10.1016/j.jacr.2019.04.011

J Am Coll Radiol

31092342

Echocardiographic Assessment of Right Ventricular Function in Clinically Well Pediatric Heart Transplantation Patients and Comparison With Normal Control Subjects.

2019

537-544.e3

2019 Apr

1097-6795

<p><strong>BACKGROUND: </strong>Echocardiographic follow-up after pediatric heart transplantation is important because of the lifelong risk for rejection and resultant ventricular dysfunction. Although adult studies have shown that echocardiographic measures of right ventricular function are changed after transplantation, similar results have not been reported in the pediatric population.</p>

<p><strong>METHODS: </strong>A single-center retrospective study of echocardiograms obtained among pediatric heart transplant recipients was conducted. All echocardiograms were selected remote from transplantation, rejection, or graft vasculopathy. These criteria identified 127 patients. Right ventricular systolic function was measured using tricuspid annular plane systolic excursion, fractional area change (FAC), and peak systolic tricuspid annular tissue velocity (S'). Results were compared with those in 380 healthy age-matched echocardiographic control subjects.</p>

<p><strong>RESULTS: </strong>Tricuspid annular plane systolic excursion values in pediatric heart transplant recipients were significantly lower than in control subjects at all ages (P&nbsp;&lt;&nbsp;.0001), with a mean Z score of -3.38. FAC and S' did not vary by age in control patients &gt;6&nbsp;months of age. FAC values in transplantation patients were significantly decreased compared with those in control subjects (P&nbsp;&lt;&nbsp;.0001), but 83% of transplantation patients had FAC values within the control-derived normal range. S' values were also significantly lower in transplantation patients than control subjects (P&nbsp;&lt;&nbsp;.0001).</p>

<p><strong>CONCLUSIONS: </strong>Heart transplantation patients have significantly decreased quantitative metrics of right ventricular function relative to healthy control subjects; longitudinal shortening (tricuspid annular plane systolic excursion and S') is particularly affected. FAC is relatively preserved and may be a better metric in this population. These results establish nomograms of RV function in pediatric heart transplantation patients and in normal pediatric control subjects, which may allow quantification of changes in this vulnerable population.</p>

10.1016/j.echo.2019.01.015

J Am Soc Echocardiogr

30954122