Emily L. McGinley

Nationwide Trends of Severe Sepsis in the 21st Century (2000–2007)

BACKGROUND Severe sepsis is common and often fatal. The expanding armamentarium of evidence-based therapies has improved the outcomes of persons with this disease. However, the existing national estimates of the frequency and outcomes of severe sepsis were made before many of the recent therapeutic advances. Therefore, it is important to study the outcomes of this disease in an aging US population with rising comorbidities. METHODS We used the Healthcare Costs and Utilization Projects Nationwide Inpatient Sample (NIS) to estimate the frequency and outcomes of severe sepsis hospitalizations between 2000 and 2007. We identified hospitalizations for severe sepsis using International Classification of Diseases, Ninth Revision, Clinical Modification codes indicating the presence of sepsis and organ system failure. Using weights from NIS, we estimated the number of hospitalizations for severe sepsis in each year. We combined these with census data to determine the number of severe sepsis hospitalizations per 100,000 persons. We used discharge status to identify in-hospital mortality and compared mortality rates in 2000 with those in 2007 after adjusting for demographics, number of organ systems failing, and presence of comorbid conditions. RESULTS The number of severe sepsis hospitalizations per 100,000 persons increased from 143 in 2000 to 343 in 2007. The mean number of organ system failures during admission increased from 1.6 to 1.9 (P < .001). The mean length of hospital stay decreased from 17.3 to 14.9 days. The mortality rate decreased from 39% to 27%. However, more admissions ended with discharge to a long-term care facility in 2007 than in 2000 (35% vs 27%, P < .001). CONCLUSIONS An increasing number of admissions for severe sepsis combined with declining mortality rates contribute to more individuals surviving to hospital discharge. Importantly, this leads to more survivors being discharged to skilled nursing facilities and home with in-home care. Increased attention to this phenomenon is warranted.

Excess hospitalisation burden associated with Clostridium difficile in patients with inflammatory bowel disease

Background: Clostridium difficile is an important cause of diarrhoea in hospitalised patients. An increasing number of cases of C difficile colitis occur in patients with inflammatory bowel disease (IBD)—Crohn’s disease (CD), ulcerative colitis (UC). Objective: To estimate the potential excess morbidity and mortality associated with C difficile in hospitalised patients with IBD. Methods: Data from the Nationwide Inpatient Sample (2003) were analysed and outcomes were examined of patients hospitalised with both C difficile colitis and IBD compared with those hospitalised for either condition alone. The primary outcome was in-hospital mortality. A subgroup analysis was also performed comparing outcomes of C difficile infection in patients with CD and UC. Results: 2804 discharges were diagnosed as having both C difficile and IBD, 44 400 as having C difficile alone, and 77 366 as having IBD alone. On multivariate analysis, patients in the C difficile–IBD group had a four times greater mortality than patients admitted to hospital for IBD alone (aOR = 4.7, 95% CI 2.9 to 7.9) or C difficile alone (aOR = 2.2, 95% CI 1.4 to 3.4), and stayed in the hospital for three days longer (95% CI 2.3 to 3.7 days). Significantly higher mortality, endoscopy and surgery rates were found in patients with UC compared with CD (p<0.05), but no significant difference in length of stay or median hospital charge between the two groups was seen. Conclusions: C difficile colitis is associated with a significant healthcare burden in hospitalised patients with IBD and carries a higher mortality than in patients with C difficile without underlying IBD.

Inflammatory bowel disease in the elderly is associated with worse outcomes: A national study of hospitalizations

Background: Inflammatory bowel disease (IBD) has a bimodal peak of incidence with ≈15% of the cases manifesting after 65 years. Previous reports on the outcomes of IBD in the elderly have been single‐center studies or have predated the use of biologics. The aim of our study was to compare outcomes of IBD‐related hospitalizations in a nationwide representative cohort of patients 65 years and older with younger patients. Methods: This was a cross‐sectional study utilizing data from the Nationwide Inpatient Sample (NIS) for the year 2004. We identified all IBD‐related hospitalizations through the presence of the appropriate ICD‐9‐CM codes for Crohns disease, ulcerative colitis, or associated complications. We compared the differences in disease presentation as well the frequency of utilization of different interventions. We calculated the adjusted odds of mortality in older compared to the younger IBD patients using multivariate logistic regression. Results: Patients older than 65 years accounted for ≈25% of all IBD‐related hospitalizations in 2004. They were less likely to be hospitalized with fistulizing (4.0 versus 8.8%, P < 0.001) or stricturing disease (4.0 versus 5.8%, P = 0.001). Even after adjusting for comorbidity, they had higher in‐hospital mortality (odds ratio [OR] 3.91, 95% confidence interval [CI] 2.50–6.11). Older patients with fistulizing disease are more likely to undergo surgery (OR 1.55, 95% CI 1.00–2.40). Among IBD patients who underwent surgery, older patients also had a longer postoperative stay (1.73 days, 95% CI 1.04–2.21). Conclusions: Older patients with IBD‐related hospitalizations have substantial morbidity and higher mortality than younger patients. Further research is needed to better characterize the natural history and treatment outcomes in this cohort.

Outcomes of Weekend Admissions for Upper Gastrointestinal Hemorrhage: A Nationwide Analysis

BACKGROUND & AIMS Previous studies have identified a weekend effect in outcomes of patients with various medical conditions suggesting worse outcomes for weekend admissions. The aim of our study was to analyze if weekend admissions for upper gastrointestinal hemorrhage (UGIH) have higher mortality and longer hospital stay compared with those admitted on weekdays, and to examine if this effect differs by hospital teaching status. METHODS This was a cross-sectional study using the Nationwide Inpatient Sample 2004. A total of 28,820 discharges with acute variceal hemorrhage (AVH) and 391,119 discharges with acute nonvariceal UGIH (NVUGIH) were identified through appropriate International Classification of Diseases, ninth edition codes. Admissions were considered to be weekend admissions if they were admitted between midnight on Friday through midnight on Sunday. In-hospital mortality, frequency, and timing of endoscopy were measured. RESULTS On multivariate analysis, NVUGIH patients admitted on weekends had higher adjusted in-hospital mortality (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.09-1.35) and were less likely to undergo early endoscopy within 1 day of hospitalization (OR, 0.64; 95% CI, 0.61-0.68). Weekend admission was not predictive of in-hospital mortality in patients with AVH (OR, 0.94; 95% CI, 0.75-1.18), but was associated with lower likelihood of early endoscopy in nonteaching hospitals (OR, 0.65; 95% CI, 0.51-0.82). Early endoscopy was associated with significantly shorter hospital stays (NVUGIH, -1.08 days; AVH, -2.35 days) and lower hospitalization charges (NVUGIH, -

Clostridium difficile Is Associated With Poor Outcomes in Patients With Cirrhosis: A National and Tertiary Center Perspective

1958; AVH, -

Temporal trends in disease outcomes related to Clostridium difficile infection in patients with inflammatory bowel disease

8870). CONCLUSIONS Patients with NVUGIH admitted on the weekend had higher mortality and lower rates of early endoscopy. Patient with AVH admitted to nonteaching hospitals also had lower utilization of early endoscopy, but no difference in survival. There is a need for research into identifying the reasons for the weekend effect.

Does it matter where you are hospitalized for inflammatory bowel disease? A nationwide analysis of hospital volume.

OBJECTIVES:Clostridium difficile–associated disease (CDAD) is associated with antibiotic use, acid suppression, and hospitalization, all of which occur frequently in cirrhosis. The aim was to define the effect of CDAD on outcomes and identify risk factors for its development in cirrhosis.METHODS:Case–control studies using the de-identified national (Nationwide Inpatient Sample, NIS) and an identified liver transplant center database of hospitalized cirrhotics with and without CDAD were performed. The NIS 2005 was queried for mortality, charges, and length of stay (LOS) in cirrhotics with/without CDAD. Outcomes of cirrhosis and infections were also analyzed. In the transplant center database, risk factors for CDAD were defined in hospitalized cirrhotics with/without CDAD who were age matched in a 1:2 ratio.RESULTS:The NIS 2005 included 1,165 cirrhotics with and 82,065 without CDAD. Cirrhotics with CDAD had a significantly higher mortality (13.8% vs. 8.2%, P<0.001), LOS (14.4 days vs. 6.7 days, P<0.001), and charges (

Infection-related hospitalizations are associated with increased mortality in patients with inflammatory bowel diseases

79,351 vs.

Ambient air pollution correlates with hospitalizations for inflammatory bowel disease: An ecologic analysis

35,686, P<0.001) compared with those without CDAD. On multivariate analysis, CDAD was associated with higher mortality (odds ratio (OR) 1.55, 95% confidence interval (CI) 1.29–1.85), charges, and LOS despite controlling for cirrhosis complications and infections. In the transplant center database, 54 cirrhotics with and 108 cirrhotics without CDAD were included. Outpatient spontaneous bacterial peritonitis prophylaxis (35% vs. 13%, P=0.01), inpatient antibiotic (63% vs. 35%, P=0.0001), and proton pump inhibitor (PPI) use (74% vs. 31%, P=0.0001) were significantly higher in those with CDAD.CONCLUSIONS:Cirrhotics with CDAD have a higher mortality, LOS, and charges on the NIS 2005 compared with those without CDAD. Antibiotic and PPI use are risk factors for CDAD development in hospitalized cirrhotics.

Deep Vein Thrombosis and Pulmonary Embolism in Hospitalized Patients with Cirrhosis: A Nationwide Analysis

Background: Clostridium difficile has emerged as an important pathogen in patients with inflammatory bowel disease (IBD) and is associated with increased morbidity and mortality. No studies have examined the temporal change in severity of C. difficile infection (CDI) complicating IBD. Methods: Using data from the Nationwide Inpatient Sample, we identified all IBD‐related hospitalizations during the years 1998, 2004, and 2007 and examined hospitalizations with a coexisting diagnosis of C. difficile. We compared the absolute outcomes of in‐hospital mortality and colectomy in the C. difficile‐IBD cohort during these timepoints, and also examined these outcomes relative to non‐C. difficile IBD controls during each corresponding year. Results: During 1998, 2004, and 2007, approximately 1.4%, 2.3%, and 2.9% of all IBD hospitalizations nationwide were complicated by CDI (P < 0.001). The absolute mortality in the C. difficile‐IBD cohort increased from 5.9%–7.2% (P = 0.052) with a nonsignificant increase in colectomy rate from 3.8%–4.5% between 1998 and 2007. Compared to non‐C. difficile IBD controls, there was an increase in the relative mortality risk associated with C. difficile from 1998 (odds ratio [OR] 2.38, 95% confidence interval [CI]: 1.52–3.72) to 2007 (OR 3.38, 95% CI: 2.66–4.29) (P = 0.15) with a significant increase in total colectomy odds from 1998 (OR 1.39, 95% CI: 0.81–2.37) to 2007 (OR 2.51, 95% CI: 1.90–3.34) (P = 0.03). Conclusion: There has been a temporal increase nationwide in CDI complicating IBD hospitalizations. The excess morbidity associated with C. difficile infection in hospitalized IBD patients has increased between 1998 and 2007. (Inflamm Bowel Dis 2011;)