Vishal Jani

A National Perspective of Do-Not-Resuscitate Order Utilization Predictors in Intracerebral Hemorrhage

Nontraumatic intracerebral hemorrhage (ICH) is associated with substantial morbidity and mortality. Do-not-resuscitate (DNR) orders are linked to poorer outcomes in patients with ICH, possibly due to less active management. Demographic, regional, and social factors, not related to ICH severity, have not been adequately looked at as significant predictors of DNR utilization. We reviewed the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) database in 2011 for adult ICH admissions and DNR status. We generated hierarchical 2-level multivariate regression models to estimate adjusted odds ratios. We analyzed 25 768 ICH hospitalizations, 18% of which (4620 hospitalizations) had DNR orders, corresponding to national estimates of 126 254 and 22 668, respectively. In multivariable regression, female gender, white or Hispanic/Latino ethnicity, no insurance coverage, and teaching hospitals were significantly associated with increased DNR utilization after adjusting for confounders. There was also significantly more interhospital variability in the lowest quartile of hospital volume. In conclusion, demographic factors and insurance status are significantly associated with increased DNR utilization, with more individual hospital variability in low-volume hospitals. The reasons for this are likely qualitative and linked to patient, provider, and hospital practices.

A Nationwide Analysis of Outcomes of Weekend Admissions for Intracerebral Hemorrhage Shows Disparities Based on Hospital Teaching Status

Background and Purpose: With the “weekend effect” being well described, the Brain Attack Coalition released a set of “best practice” guidelines in 2005, with the goal to uniformly provide standard of care to patients with stroke. We attempted to define a “weekend effect” in outcomes among patients with intracranial hemorrhage (ICH) over the last decade, utilizing the Nationwide Inpatient Sample (NIS) data. We also attempted to analyze the trend of such an effect. Materials and Methods: We determined the association of ICH weekend admissions with hospital outcomes including mortality, adverse discharge, length of stay, and cost compared to weekday admissions using multivariable logistic regression. We extracted our study cohort from the NIS, the largest all-payer data set in the United States. Results: Of 485 329 ICH admissions from 2002 to 2011, 27.5% were weekend admissions. Overall, weekend admissions were associated with 11% higher odds of in-hospital mortality. When analyzed in 3-year groups, excess mortality of weekend admissions showed temporal decline. There was higher mortality with weekend admissions in nonteaching hospitals persisted (odds ratios 1.16, 1.13, and 1.09, respectively, for 3-year subgroups). Patients admitted during weekends were also 9% more likely to have an adverse discharge (odds ratio 1.09; 95% confidence interval: 1.07-1.11; P < .001) with no variation by hospital status. There was no effect of a weekend admission on either length of stay or cost of care. Conclusion: Nontraumatic ICH admissions on weekends have higher in-hospital mortality and adverse discharge. This demonstrates need for in-depth review for elucidating this discrepancy and stricter adherence to standard-of-care guidelines to ensure uniform care.

116 Effect of Annual Hospital Procedure Volume on Outcomes After Mechanical Thrombectomy in Acute Ischemic Stroke Patients: An Analysis of 13 502 Procedures.

We aim to analyze the impact of annual hospital volume on outcomes of endovascular mechanical thrombectomy (EMT) for acute ischemic stroke (AIS). In the recent past, increasing number of hospitals are acquiring capabilities for EMT procedure for the treatment of AIS, including some low-volume centers. There are few data on outcomes comparing these hospitals with high-volume centers.We queried the National Inpatient Sample from 2008 to 2011 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) diagnosis codes 433 to 437.1 in any position for AIS. Adult patients with ICD-9-CM procedure code 39.74 for mechanical thrombectomy were included in the final cohort. Annual hospital procedure volume was computed using the unique hospital identification number (HOSPID) and was dichotomized corresponding to <10 (low) and ≥10 (high) procedures per year. Comorbid conditions were defined using the Deyo modification of the Charlson Comorbidity Index (CCI). Primary outcomes were in-hospital mortality and any complications (combination of in-hospital mortality, intracerebral hemorrhage, vascular complications). We built hierarchical 2-level models adjusted for multiple confounding factors, with HOSPID incorporated as random effects in the model.A total of 13 502 procedures were available for analysis, of which 3352 (24.8%) were performed in low-volume hospitals. Overall in-hospital mortality and any complications were higher in low-volume hospitals 25.6% vs 21.1% (P <.001) and 34.2% vs 30.2% (P <.001), respectively. However, in a multivariate hierarchical model, low-volume hospitals were not associated with higher odds of in-hospital mortality and any complications (odds ratio [OR], 0.95; 95% confidence interval [95% CI], 0.74-1.23, P =.684) and (OR, 0.96; 95% CI, 0.76-1.21, P =.720). Similar results were observed even in sensitivity analysis.Although the proportion of in-hospital mortality was higher among patients undergoing EMT at low-volume centers, risk-adjusted odds of in-hospital mortality were similar to high-volume EMT centers. Our findings raise important question on this phenomena for EMT procedure for AIS and warrant further studies.INTRODUCTION We aim to analyze the impact of annual hospital volume on outcomes of endovascular mechanical thrombectomy (EMT) for acute ischemic stroke (AIS). In the recent past, increasing number of hospitals are acquiring capabilities for EMT procedure for the treatment of AIS, including some low-volume centers. There are few data on outcomes comparing these hospitals with high-volume centers. METHODS We queried the National Inpatient Sample from 2008 to 2011 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) diagnosis codes 433 to 437.1 in any position for AIS. Adult patients with ICD-9-CM procedure code 39.74 for mechanical thrombectomy were included in the final cohort. Annual hospital procedure volume was computed using the unique hospital identification number (HOSPID) and was dichotomized corresponding to <10 (low) and ≥10 (high) procedures per year. Comorbid conditions were defined using the Deyo modification of the Charlson Comorbidity Index (CCI). Primary outcomes were in-hospital mortality and any complications (combination of in-hospital mortality, intracerebral hemorrhage, vascular complications). We built hierarchical 2-level models adjusted for multiple confounding factors, with HOSPID incorporated as random effects in the model. RESULTS A total of 13 502 procedures were available for analysis, of which 3352 (24.8%) were performed in low-volume hospitals. Overall in-hospital mortality and any complications were higher in low-volume hospitals 25.6% vs 21.1% (P < .001) and 34.2% vs 30.2% (P < .001), respectively. However, in a multivariate hierarchical model, low-volume hospitals were not associated with higher odds of in-hospital mortality and any complications (odds ratio [OR], 0.95; 95% confidence interval [95% CI], 0.74-1.23, P = .684) and (OR, 0.96; 95% CI, 0.76-1.21, P = .720). Similar results were observed even in sensitivity analysis. CONCLUSION Although the proportion of in-hospital mortality was higher among patients undergoing EMT at low-volume centers, risk-adjusted odds of in-hospital mortality were similar to high-volume EMT centers. Our findings raise important question on this phenomena for EMT procedure for AIS and warrant further studies.