Meng-Shiou Shieh

Hospitalizations, costs, and outcomes of severe sepsis in the United States 2003 to 2007.

Objectives:To assess trends in number of hospitalizations, outcomes, and costs of severe sepsis in the United States. Design:Temporal trends study using the Nationwide Inpatient Sample. Patients:Adult patients with severe sepsis (defined as a diagnosis of sepsis and organ dysfunction) diagnosed between 2003 and 2007. Measurements and Main Results:We determined the weighted frequency of patients hospitalized with severe sepsis. We calculated age- and sex-adjusted population-based mortality rates for severe sepsis per 100,000 population and also used logistic regression to adjust in-hospital mortality rates for patient characteristics. We calculated inflation-adjusted costs using hospital-specific cost-to-charge ratios. We identified a rapid steady increase in the number of cases of severe sepsis, from 415,280 in 2003 to 711,736 in 2007 (a 71% increase). The total hospital costs for all patients with severe sepsis increased from

Association of diagnostic coding with trends in hospitalizations and mortality of patients with pneumonia, 2003-2009

15.4 billion in 2003 to

Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease

24.3 billion in 2007 (57% increase). The proportion of patients with severe sepsis and only a single organ dysfunction decreased from 51% in 2003 to 45% in 2007 (p < .001), whereas the proportion of patients with three or four or more organ dysfunctions increased 1.19-fold and 1.51-fold, respectively (p < .001). During the same time period, we observed 2% decrease per year in hospital mortality for patients with severe sepsis (p < .001), as well as a slight decrease in the length of stay (9.9 days to 9.2 days; p < .001) and a significant decrease in the geometric mean cost per case of severe sepsis (

What is the best method for estimating the burden of severe sepsis in the United States

20,210 per case in 2003 and

Epidemiology and outcomes of acute respiratory failure in the United States, 2001 to 2009: a national survey

19,330 in 2007; p = .025). Conclusions:The increase in the number of hospitalizations for severe sepsis coupled with declining in-hospital mortality and declining geometric mean cost per case may reflect improvements in care or increases in discharges to skilled nursing facilities; however, these findings more likely represent changes in documentation and hospital coding practices that could bias efforts to conduct national surveillance.

Association Between Antibiotic Treatment and Outcomes in Patients Hospitalized With Acute Exacerbation of COPD Treated With Systemic Steroids

CONTEXT Recent reports suggest that the mortality rate of patients hospitalized with pneumonia has steadily declined. While this may be the result of advances in clinical care or improvements in quality, it may also represent an artifact of changes in diagnostic coding. OBJECTIVE To compare estimates of trends in hospitalizations and inpatient mortality among patients with pneumonia using 2 approaches to case definition: one limited to patients with a principal diagnosis of pneumonia, and another that includes patients with a secondary diagnosis of pneumonia if the principal diagnosis is sepsis or respiratory failure. DESIGN, SETTING, AND PARTICIPANTS Trends study using data from the 2003-2009 releases of the Nationwide Inpatient Sample. MAIN OUTCOME MEASURES Change in the annual hospitalization rate and change in inpatient mortality over time. RESULTS From 2003 to 2009, the annual hospitalization rate for patients with a principal diagnosis of pneumonia declined 27.4%, from 5.5 to 4.0 per 1000, while the age- and sex-adjusted mortality decreased from 5.8% to 4.2% (absolute risk reduction [ARR], 1.6%; 95% CI, 1.4%-1.9%; relative risk reduction [RRR], 28.2%; 95% CI, 25.2%-31.2%). Over the same period, hospitalization rates of patients with a principal diagnosis of sepsis and a secondary diagnosis of pneumonia increased 177.6% from 0.4 to 1.1 per 1000, while inpatient mortality decreased from 25.1% to 22.2% (ARR, 3.0%; 95% CI, 1.6%-4.4%; RRR, 12%; 95% CI, 7.5%-16.1%); hospitalization rates for patients with a principal diagnosis of respiratory failure and a secondary diagnosis of pneumonia increased 9.3% from 0.44 to 0.48 per 1000 and mortality declined from 25.1% to 19.2% (ARR, 6.0%; 95% CI, 4.6%-7.3%; RRR, 23.7%; 95% CI, 19.7%-27.8%). However, when the 3 groups were combined, the hospitalization rate declined only 12.5%, from 6.3 to 5.6 per 1000, while the age- and sex-adjusted inpatient mortality rate increased from 8.3% to 8.8% (AR increase, 0.5%; 95% CI, 0.1%-0.9%; RR increase, 6.0%; 95% CI, 3.3%-8.8%). Over this same time frame, the age-, sex-, and comorbidity-adjusted mortality rate declined from 8.3% to 7.8% (ARR, 0.5%; 95% CI, 0.2%-0.9%; RRR, 6.3%; 95% CI, 3.8%-8.8%). CONCLUSIONS From 2003 to 2009, hospitalization and inpatient mortality rates for patients with a principal diagnosis of pneumonia decreased substantially, whereas hospitalizations with a principal diagnosis of sepsis or respiratory failure accompanied by a secondary diagnosis of pneumonia increased and mortality declined. However, when the 3 pneumonia diagnoses were combined, the decline in the hospitalization rate was attenuated and inpatient mortality was little changed, suggesting an association of these results with temporal trends in diagnostic coding.

Variation in Resource Utilization for the Management of Uncomplicated Community-Acquired Pneumonia across Community and Children's Hospitals

IMPORTANCE Small clinical trials have shown that noninvasive ventilation (NIV) is efficacious in reducing the need for intubation and improving short-term survival among patients with severe exacerbations of chronic obstructive pulmonary disease (COPD). Little is known, however, about the effectiveness of NIV in routine clinical practice. OBJECTIVE To compare the outcomes of patients with COPD treated with NIV to those treated with invasive mechanical ventilation (IMV). DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cohort study of 25 628 patients hospitalized for exacerbation of COPD who received mechanical ventilation on the first or second hospital day at 420 US hospitals participating in the Premier Inpatient Database. EXPOSURES Initial ventilation strategy. MAIN OUTCOMES AND MEASURES In-hospital mortality, hospital-acquired pneumonia, hospital length of stay and cost, and 30-day readmission. RESULTS In the study population, a total of 17 978 (70%) were initially treated with NIV on hospital day 1 or 2. When compared with those initially treated with IMV, NIV-treated patients were older, had less comorbidity, and were less likely to have concomitant pneumonia present on admission. In a propensity-adjusted analysis, NIV was associated with lower risk of mortality than IMV (odds ratio [OR] 0.54; [95% CI, 0.48-0.61]). Treatment with NIV was associated with lower risk of hospital-acquired pneumonia (OR, 0.53 [95% CI, 0.44-0.64]), lower costs (ratio, 0.68 [95% CI, 0.67-0.69]), and a shorter length of stay (ratio, 0.81 [95% CI, 0.79-0.82]), but no difference in 30-day all-cause readmission (OR, 1.04 [95% CI, 0.94-1.15]) or COPD-specific readmission (OR, 1.05 [95% CI, 0.91-1.22]). Propensity matching attenuated these associations. The benefits of NIV were similar in a sample restricted to patients younger than 85 years and were attenuated among patients with higher levels of comorbidity and concomitant pneumonia. Using the hospital as an instrumental variable, the strength of association between NIV and mortality was modestly attenuated (OR, 0.66 [95% CI, 0.47-0.91]). In sensitivity analyses, the benefit of NIV was robust in the face of a strong hypothetical unmeasured confounder. CONCLUSIONS AND RELEVANCE In a large retrospective cohort study, patients with COPD treated with NIV at the time of hospitalization had lower inpatient mortality, shorter length of stay, and lower costs compared with those treated with IMV.

Variation and Outcomes Associated With Direct Hospital Admission Among Children With Pneumonia in the United States

PURPOSE The aim of the study was to compare estimates of hospitalizations, outcomes, and costs produced by 2 approaches for defining severe sepsis. METHODS We used the Nationwide Inpatient Sample to study adults hospitalized in the United States in 2007. We defined severe sepsis using 2 previously published algorithms: (1) the presence of a principal or secondary diagnosis of septicemia combined with organ dysfunction or (2) the presence of a principal or secondary diagnosis of septicemia or another infection (eg, pneumonia) combined with organ dysfunction. For each approach, we calculated the weighted frequency of hospitalizations, population-based mortality rates, and geometric mean costs. RESULTS A total of 719099 (SD, 16676) hospitalizations had a diagnosis of septicemia and a diagnosis of organ dysfunction. A total of 2.5 million hospitalizations were recorded, with a diagnosis code for either septicemia or infection combined with a diagnosis code for organ dysfunction. Hospitalizations without a diagnosis code for septicemia had lower rates of respiratory failure (35% vs 51%, P < .001) or shock (20% vs 46%, P < .001), lower in-hospital mortality (8% vs 29%, P < .001), and lower mean costs. CONCLUSIONS An approach that requires a diagnosis code for septicemia and a diagnosis code for organ dysfunction yields estimates of disease burden and outcomes that are more consistent with chart-based studies.

Comparative Effectiveness of Ceftriaxone in Combination With a Macrolide Compared With Ceftriaxone Alone for Pediatric Patients Hospitalized With Community-acquired Pneumonia

BACKGROUND The objective of this study was to evaluate trends in hospitalization, cost, and short-term outcomes in acute respiratory failure (ARF) between 2001 and 2009 in the United States. METHODS Using the Nationwide Inpatient Sample we identified cases of ARF based on International Classification for Diseases, Ninth Revision, Clinical Modification codes. We calculated weighted frequencies of ARF hospitalizations by year and estimated population-adjusted incidence and mortality rates. We used logistic regression to examine hospital mortality rates over time while adjusting for changes in demographic characteristics and comorbidities of patients. RESULTS The number of hospitalizations with a diagnosis of ARF rose from 1,007,549 in 2001 to 1,917,910 in 2009, with an associated increase in total hospital costs from

Validation and Comparison of Seven Mortality Prediction Models for Hospitalized Patients With Acute Decompensated Heart Failure

30.1 billion to