Mohammed J. Saeed

30-day hospital readmission following otolaryngology surgery: Analysis of a state inpatient database

Determine patient and hospital‐level risk factors associated with 30‐day readmission for patients undergoing inpatient otolaryngologic surgery.

Postoperative care fragmentation and thirty‐day unplanned readmissions after head and neck cancer surgery

Postdischarge care fragmentation, readmission to a hospital other than the one performing the surgery, has not been described in head and neck cancer patients. We sought to determine the frequency, risk factors, and outcomes for head and neck cancer patients experiencing postdischarge care fragmentation.

Procedure-specific surgical site infection incidence varies widely within certain National Healthcare Safety Network surgery groups

BACKGROUND The National Healthcare Safety Network (NHSN) classifies surgical procedures into 40 categories. The objective of this study was to determine surgical site infection (SSI) incidence for clinically defined subgroups within 5 heterogeneous NHSN surgery categories. METHODS This is a retrospective cohort study using the longitudinal State Inpatient Database. We identified 5 groups of surgical procedures (amputation; bile duct, liver or pancreas [BILI]; breast; colon; and hernia) using ICD-9-CM procedure codes in community hospitals in California, Florida, and New York from January 2009-September 2011 in persons aged ≥18 years. Each of these 5 categories was classified to more specific surgical procedures within the group. The 90-day SSI rates were calculated using ICD-9-CM diagnosis codes. RESULTS There were 62,901 amputation surgeries, 33,358 BILI surgeries, 72,058 breast surgeries, 125,689 colon surgeries, and 85,745 hernia surgeries in 349,298 people. The 90-day SSI rates varied significantly within each of the 5 subgroups. Within the BILI category, bile duct, pancreas, and laparoscopic liver procedures had SSI rates of 7.2%, 17.2%, and 2.2%, respectively (P < .0001 for each) compared with open liver procedures (11.1% SSI). CONCLUSION The 90-day SSI rates varied widely within certain NHSN categories. Risk adjustment for specific surgery type is needed to make valid comparisons between hospitals.

Readmission and Late Mortality After Critical Illness in Childhood.

Objectives: Little is known about the ongoing mortality risk and healthcare utilization among U.S. children after discharge from a hospitalization involving ICU care. We sought to understand risks for hospital readmission and trends in mortality during the year following ICU discharge. Design: Retrospective observational cohort study. Setting: This study was performed using administrative claims data from 2006-2013 obtained from the Truven Health Analytics MarketScan Database. Subjects: We included all children in the dataset admitted to a U.S. ICU less than or equal to 18 years old. Interventions: The primary outcome was nonelective readmission in the year following discharge. Risk of rehospitalization was determined using a Cox proportional hazards model. Measurements and Main Results: We identified 109,130 children with at least one ICU admission in the dataset. Over three quarters of the index ICU admissions (78.6%) had an ICU length of stay less than or equal to 3 days, and the overall index hospitalization mortality rate was 1.4%. In multivariate analysis, risk of nonelective readmission for children without cancer was higher with longer index ICU admission length of stay, younger age, and several chronic and acute conditions. By the end of the 1-year observation period, 36.0% of children with an index ICU length of stay greater than or equal to 14 days had been readmitted, compared with only 13.9% of children who had an index ICU length of stay equals to 1 day. Mortality in the year after ICU discharge was low overall (106 deaths per 10,000 person-years of observation) but was high among children with an initial index ICU admission length of stay greater than or equal to 14 days (599 deaths per 10,000 person-years). Conclusions: Readmission after ICU care is common. Further research is needed to investigate the potentially modifiable factors affecting likelihood of readmissions after discharge from the ICU. Although late mortality was relatively uncommon overall, it was 10-fold higher in the year after ICU discharge than in the general U.S. pediatric population.

Diabetes Mellitus is Associated With Higher Risk of Developing Decompensated Cirrhosis in Chronic Hepatitis C Patients.

Goals: To investigate the association of diabetes with risk of decompensated cirrhosis in patients with chronic hepatitis C (CHC). Background: Direct-acting antivirals are highly effective in treating CHC but very expensive. CHC patients at high risk of progression to symptomatic liver disease may benefit most from early treatment. Study: We conducted a retrospective cohort study using the 2006 to 2013 Truven Health Analytics MarketScan Commercial Claims and Encounters database including inpatient, outpatient, and pharmacy claims from private insurers. CHC and cirrhosis were identified using ICD-9-CM diagnosis codes; baseline diabetes was identified by diagnosis codes or antidiabetic medications. CHC patients were followed to identify decompensated cirrhosis. Multivariable Cox proportional hazards regression was used to model the risk of decompensated cirrhosis by baseline cirrhosis. Results: There were 75,805 CHC patients with median 1.9 years follow-up. A total of 10,317 (13.6%) of the CHC population had diabetes. The rates of decompensated cirrhosis per 1000 person-years were: 185.5 for persons with baseline cirrhosis and diabetes, 119.8 for persons with cirrhosis and no diabetes, 35.3 for persons with no cirrhosis and diabetes, and 17.1 for persons with no cirrhosis and no diabetes. Diabetes was associated with increased risk of decompensated cirrhosis in persons with baseline cirrhosis (adjusted hazard ratio=1.4; 95% confidence interval, 1.3-1.6) and in persons without baseline cirrhosis (adjusted hazard ratio=1.9; 95% confidence interval, 1.7-2.1). Conclusions: In a privately insured US population with CHC, the adjusted risk of decompensated cirrhosis was higher in diabetic compared with nondiabetic patients. Diabetes status should be included in prioritization of antiviral treatment.

Association of Inferior Vena Cava Filter Placement for Venous Thromboembolic Disease and a Contraindication to Anticoagulation With 30-Day Mortality

Key Points Question What is the association of inferior vena cava filter placement with 30-day mortality in patients with venous thromboembolic disease and a contraindication to anticoagulation? Findings In this cohort study, using 2 different statistical methods with adjustment for immortal time bias, inferior vena cava filter placement in patients with venous thromboembolic disease and a contraindication to anticoagulation was associated with an increased risk of 30-day mortality. Meaning Randomized clinical trials are needed to define the role of inferior vena cava filter placement in patients with venous thromboembolic disease and a contraindication to anticoagulation.

Trends in Inferior Vena Cava Filter Placement by Indication in the United States From 2005 to 2014

Methods | We used discharge data for adults (aged >18 years) from the Nationwide Inpatient Sample (January 1, 2005, to December 31, 2011) and the National Inpatient Sample (January 1, 2012, to December 31, 2014), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality (https://www .hcup-us.ahrq.gov/db/nation/nis/nisdocumentation.jsp). Inferior vena cava filter placement was identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure code 38.7. Contraindications to anticoagulation were as defined by Moore et al.3 The Washington University Office of Human Research Protection granted this study a waiver from institutional review board oversight. We plotted weighted rates of total IVC filter placement, filter placement by venous thromboembolism (VTE) diagnosis (deep vein thrombosis [DVT] or pulmonary embolism [PE]), and filter placement by contraindication to anticoagulation. We calculated rates of DVT and PE per 100 000 hospital discharges by year. A map of IVC filter placement rates per 100 000 hospital discharges by US census division in 2014 was created to analyze geographic variation. SAS Enterprise Guide, version 7.1 (SAS Institute Inc) was used for all analyses. Results | The IVC filter placement rate per 100 000 hospitalizations increased from 322.1 (n = 99 779) in 2005 to 412.0 (n = 129 026) in 2010, decreased to 374.1 (n = 117 731) in 2011, and continued declining to 321.8 (n = 95 735) in 2014 (Figure 1A). The percentage of prophylactic IVC filter placement decreased from 28.9% in 2005 to 22.6% in 2014. Rates of IVC filter placement with a contraindication to anticoagulation per 100 000 hospitalizations decreased from 188.2 (n = 58 946) in 2010 to 167.3 (n = 49 775) in 2014; the rates of filter placement without coding for contraindication to anticoagulation per 100 000 hospitalizations decreased from 223.8 (n = 70 080) in 2010 to 154.5 (n = 45 960) in 2014 (Figure 1B). The rate of DVT per 100 000 hospitalizations increased from 852.1 (n = 263 978) in 2005 to 935.0 (n = 299 757) in 2008 and then decreased to 841.3 (n = 250 300) in 2014. The rate of PE increased from 719.0 (n = 222 732) in 2005 to 1138.6 (n = 338 770) in 2014. The Mid-Atlantic census division had the highest rate of IVC filter placement in 2014; the Pacific division had the lowest rate (Figure 2).

A Population-Based Analysis of Time to Surgery and Travel Distances for Brachial Plexus Surgery

PURPOSE Despite the importance of timely evaluation for patients with brachial plexus injuries (BPIs), in clinical practice we have noted delays in referral. Because the published BPI experience is largely from individual centers, we used a population-based approach to evaluate the delivery of care for patients with BPI. METHODS We used statewide administrative databases from Florida (2007-2013), New York (2008-2012), and North Carolina (2009-2010) to create a cohort of patients who underwent surgery for BPI (exploration, repair, neurolysis, grafting, or nerve transfer). Emergency department and inpatient records were used to determine the time interval between the injury and surgical treatment. Distances between treating hospitals and between the patients home ZIP code and the surgical hospital were recorded. A multivariable logistic regression model was used to determine predictors for time from injury to surgery exceeding 365 days. RESULTS Within the 222 patients in our cohort, median time from injury to surgery was 7.6 months and exceeded 365 days in 29% (64 of 222 patients) of cases. Treatment at a smaller hospital for the initial injury was significantly associated with surgery beyond 365 days after injury. Patient insurance type, travel distance for surgery, distance between the 2 treating hospitals, and changing hospitals between injury and surgery did not significantly influence time to surgery. CONCLUSIONS Nearly one third of patients in Florida, New York, and North Carolina underwent BPI surgery more than 1 year after the injury. Patients initially treated at smaller hospitals are at risk for undergoing delayed BPI surgery. CLINICAL RELEVANCE These findings can inform administrative and policy efforts to expedite timely referral of patients with BPI to experienced centers.

Pharmacoepidemiology of cytomegalovirus prophylaxis in a large retrospective cohort of kidney transplant recipients with Medicare Part D coverage

We assembled a cohort of 21 117 kidney transplant patients from July 2006 to June 2011 with Medicare Part D coverage using US Renal Database System data to determine real‐world use of cytomegalovirus (CMV) prophylaxis. CMV prophylaxis was defined as filled prescriptions for daily oral valganciclovir (≤900 mg), ganciclovir (≤3 g), or valacyclovir (6–8 g) within 28 d of transplant. Multilevel logistic regression analyses were performed to determine factors associated with CMV prophylaxis. CMV prophylaxis (97% valganciclovir) was identified in 61% of kidney transplant recipients (median duration, 64 d); 71% of seronegative recipients of kidneys from seropositive donors (D+/R−); 63% of R+ patients; 60% of patients with unknown serostatus; and 34% of D−/R− patients. Variability in usage of prophylaxis among transplant centers was greater than variability within transplant centers. One in four transplant centers prescribed CMV prophylaxis to >60% of their D−/R− patients. CMV donor/recipient serostatus, lymphocyte‐depleting agents for induction and mycophenolate for maintenance were associated with CMV prophylaxis. CMV prophylaxis was commonly used among kidney transplant recipients. Routine prescription of CMV prophylaxis to D−/R− patients may have occurred in some transplant centers. Limiting unnecessary use of CMV prophylaxis may decrease healthcare costs and drug‐related harms.

The Comparative Epidemiology of Pediatric Severe Sepsis

Objective: To determine whether the coding strategies used to identify severe sepsis in administrative data sets could identify cases with comparable case mix, hospitalization characteristics, and outcomes as a cohort of children diagnosed with severe sepsis using strict clinical criteria. Methods: We performed a retrospective cohort study using data from 2005 to 2011 from the New York and Florida State Inpatient Databases, available from the US Healthcare Cost and Utilization Project. We compared 4 coding strategies: the single International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for (1) severe sepsis or (2) septic shock, and the algorithms developed by (3) Angus et al or (4) Martin et al, which use a combination of ICD-9-CM codes for infection and organ dysfunction. We compared the cases identified by each strategy with each other and with children enrolled in the REsearching severe Sepsis and Organ dysfunction in children: a gLobal perspectiVE (RESOLVE) trial. Results: The Angus criteria was 9 times larger (n = 23 995) than the smallest cohort, identified by the “septic shock” code (n = 2 601). Cases identified by the Angus and Martin strategies had low mortality rates, while the cases identified by the “severe sepsis” and “septic shock” codes had much higher mortality at all time points (eg, 28-day mortality of 4.4% and 7.4% vs 15.4% and 16.0%, respectively). Mortality in the “severe sepsis” and “septic shock” code cohorts was similar to that presented in the RESOLVE trial. Conclusions: The ICD-9-CM codes for “severe sepsis” and “septic shock” identify smaller but higher acuity cohorts of patients that more closely resemble the children enrolled in the largest clinical trial of pediatric severe sepsis to date.