Increased Mortality in Hip Fracture Patients With Aortic Stenosis and Pulmonary Hypertension Compared to Aortic Stenosis Alone

2021 ◽  
pp. 000313482110545
Author(s):  
Christian B. Cignoni ◽  
Steven K. M. Vuu ◽  
Huazhi Liu ◽  
Jason M. Clark ◽  
Carrie D. Watson ◽  
...  
Keyword(s):  
Pulmonary Hypertension ◽  
Aortic Stenosis ◽  
Hip Fractures ◽  
The United States ◽  
P Value ◽  
Complication Rates ◽  
Inpatient Mortality ◽  
Large Hospital ◽  
Hospital System ◽  
Level I

Introduction Hip fractures are one of the most common traumatic injuries in the United States, secondary to an aging population. Multiple comorbidities are found in patients who present to trauma centers (TCs) with isolated hip fractures (IHFs) including significant cardiac disease. Aortic stenosis (AS) among these patients has been recently shown to increase mortality. However, factors leading to death from AS are unknown. We hypothesize that pulmonary hypertension (PH) is a significant mechanism of death among IHF patients with AS. Methods This is a multicenter retrospective cohort study examining IHF patients treated at Level I and II TCs within a large hospital system from 2015 to 2019. Patients who had IHFs and AS were compared to those who had IHFs, AS, and PH. Multivariable logistic regression was used to risk adjust by age, race, insurance status, and comorbidities. The primary outcome was inpatient mortality. The secondary outcomes were hospital-acquired complications. Results A total of 1388 IHF patients with AS were included in the study. Eleven percent of these patients also had PH. The crude mortality rate was higher if IHF patients had both AS and PH compared to IHF with AS alone (9% vs 3.7%, P-value .003). After risk adjustment, a higher risk of mortality was still significant (aOR 2.56 [95% CI 1.28, 5.11]). In addition, IHF patients with both AS and PH had higher complication rates; the exposure group had higher percentage of pulmonary embolism (1.4% vs .2%, adjusted P-value .03), new-onset congestive heart failure (4.1% vs 1%, adjusted P-value .01), and sepsis/septicemia (3.5% vs 1.4%, adjusted P-value .05). Conclusion In patients with IHFs, PH and AS increase the likelihood of inpatient mortality by 2.5 times compared to AS alone. Pulmonary hypertension among IHF patients with AS is an important risk factor to identify in the preoperative period. Early identification may lead to better perioperative management and counseling of patients at higher risk of complications.

scholarly journals From ER to OR: Results After Implementation of Multidisciplinary Pathway for Fragility Hip Fractures at a Level I Trauma Center

2020 ◽  
Vol 11 ◽  
pp. 215145932092738
Author(s):  
Kenoma Anighoro ◽  
Carla Bridges ◽  
Alexander Graf ◽  
Alexander Nielsen ◽  
Tannor Court ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Hip Fractures ◽  
Trauma Center ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Complication Rates ◽  
Blood Products ◽  
Total Blood ◽  
Fragility Hip Fracture ◽  
Level I

Introduction: Hip fractures are one of the most common indications for hospitalization and orthopedic intervention. Fragility hip fractures are frequently associated with multiple comorbidities and thus may benefit from a structured multidisciplinary approach for treatment. The purpose of this article was to retrospectively analyze patient outcomes after the implementation of a multidisciplinary hip fracture pathway at a level I trauma center. Materials and Methods: A retrospective review of 263 patients over the age of 65 with fragility hip fracture was performed. Time to surgery, hospital length of stay, Charlson Comorbidity Index (CCI), American Society of Anesthesiologists, complication rates, and other clinical outcomes were compared between patients treated in the year before and after implementation of a multidisciplinary hip fracture pathway. Results: Timing to OR, hospital length of stay, and complication rates did not differ between pre- and postpathway groups. The postpathway group had a greater CCI score (pre: 3.10 ± 3.11 and post: 3.80 ± 3.18). Fewer total blood products were administered in the postpathway group (pre: 1.5 ± 1.8 and post: 0.8 ± 1.5). Discussion: The maintenance of clinical outcomes in the postpathway cohort, while having a greater CCI, indicates the same quality of care was provided for a more medically complex patient population. With a decrease in total blood products in the postpathway group, this highlights the economic importance of perioperative optimization that can be obtained in a multidisciplinary pathway. Conclusion: Implementation of a multidisciplinary hip fracture pathway is an effective strategy for maintaining care standards for fragility hip fracture management, particularly in the setting of complex medical comorbidities.

scholarly journals Outcomes of an accelerated nonsurgical management protocol for hip fractures in the elderly

2018 ◽  
Vol 26 (3) ◽  
pp. 230949901880340 ◽  
Author(s):  
Wei Xiang Lim ◽  
Ernest Beng Kee Kwek
Keyword(s):  
Length Of Stay ◽  
Elderly Patients ◽  
Hip Fractures ◽  
The Elderly ◽  
Operative Management ◽  
Nonsurgical Treatment ◽  
P Value ◽  
Complication Rates ◽  
Nonsurgical Management ◽  
Management Protocol

The majority of hip fractures in elderly patients are managed surgically with superior outcomes. However, for patients who refuse surgery or are deemed medically unfit, traction used to be the mainstay of nonsurgical treatment, which is associated with prolonged hospitalization and inpatient complications from immobility. This study, therefore, aims to evaluate the outcomes of an early wheelchair mobilization protocol as an alternative nonsurgical treatment option. This is a retrospective study of 87 elderly patients who were managed nonsurgically for their hip fractures over a 1-year period. The accelerated rehabilitation protocol did not have them on traction but were instead mobilized with assistance as soon as possible after admission. Variables collected electronically include patient demographics, fracture characteristics, inpatient mobilization milestones, inpatient complications, Modified Functional Ambulation Classification (MFAC), Modified Barthel Index (MBI) scores, and radiological findings. Patients who were younger, could sit up earlier and had a shorter length of stay, were able to ambulate better at 6 months ( p value < 0.05). Patients with femoral neck fractures and shorter length of stay had better MFAC scores. A total of 58% of patients with radiological follow-up had displacement of their fractures with age, type of fracture, and length of stay as predictors ( p value < 0.05) The Charlson’s score, day to sitting up, and day to transfer affect fracture healing ( p value < 0.05). The mean length of stay was 17 days and the 1-year mortality was 18%. Surgical therapy remains the preferred choice of management for patients with hip fractures. Early wheelchair mobilization leads to a shorter length of stay compared to traditional traction methods and comparable 1-year mortality rates with operative management. Despite this, complication rates remain high and only 48% of patients achieved ambulation by 1 year, with healing in only 24% of fractures.

scholarly journals Relationship between Hospital Volume and Inpatient Mortality Among Patients Diagnosed with Thrombotic Thrombocytopenic Purpura (TTP) in the United States

Blood ◽  
2017 ◽  
Vol 130 (Suppl_1) ◽  
pp. 675-675
Author(s):  
Smith Giri ◽  
Ranjan Pathak ◽  
Robert Franklin ◽  
Nikolai A. Podoltsev ◽  
Scott Huntington ◽  
...  
Keyword(s):  
Mortality Rate ◽  
Thrombotic Thrombocytopenic Purpura ◽  
Hospital Volume ◽  
The United States ◽  
Secondary Outcome ◽  
P Value ◽  
Inpatient Mortality ◽  
Thrombocytopenic Purpura ◽  
Significant Difference ◽  
The Mean

Abstract Introduction: Thrombotic Thrombocytopenic Purpura (TTP) is a hematological emergency with high inpatient mortality that requires prompt diagnosis and treatment. Studies outside the setting of hematologic emergencies have established hospital volume as a factor associated with clinical outcomes. We tested whether hospital volume was associated with important inpatient outcomes among patients with TTP Methods: We utilized the Nationwide Inpatient Sample (NIS) to identify adult patients ≥18 years, diagnosed with TTP using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 446.6 from the years of 2010 to 2013. We only included patients who received therapeutic plasmapheresis (ICD-9-CM procedure code 99.71) during hospitalization to capture active cases of TTP and improve coding accuracy. Using unique hospital identifier, hospital volume was computed and defined as total hospitalizations for TTP per year. Hospital volume was then divided into four quartiles. The primary outcome of interest was inpatient mortality rate, with time to initiation of plasmapheresis as our secondary outcome. Baseline age, gender, race, demographics, insurance payer, hospital region, hospital type (rural versus urban, teaching versus non-teaching), and bed size were collected. All analyses were survey adjusted to account for the complex sampling nature of the database. Appropriate bivariate methods included ANOVA and tests of trend (nptrend). Mixed effects hierarchical logistic regression analysis was used to calculate adjusted odds ratio of in-hospital mortality adjusting for potential confounders at the patient level (age, race, comorbidity, gender, insurance status) and at the hospital level (hospital location, bedsize and teaching status). All p values were two sided and the level of significance was chose was 0.05. Results: A total of 1128 unique hospitalizations for TTP were identified during the study period. The mean age was 46.3 ± 16.6 years, out of which 66% were females (n=754) and 44% were whites (n=458). The overall inpatient mortality rate was 10.9%. The distribution of hospital volume by quartiles was as follows; 1st quartile, Q1 (2 or less hospitalizations of TTP per year), 2nd quartile, Q2 (3-5/year), 3rd quartile, Q3, (6-11/year), 4th quartile, Q4 (12 and above). The mean length of stay was 14.4 ± 11.5 days and the mean cost of hospitalization was $ 177546 ± 7736. Overall there was decreasing trend in inpatient mortality with increasing hospital volumes (14.4% vs 12.8% vs 9.8% vs 6.5% from Q1-Q4 respectively; p trend 0.002). This effect was also retained in multivariate analysis adjusting for potential confounders (aOR 0.50; 95% CI 0.26-0.98; p 0.04) (Table 1). Also there was a decreasing trend in the time to plasmapheresis with increasing hospital volume (3.02 vs 2.48 vs 2.27 vs 2.09 from Q1-Q4 respectively, ANOVA p value 0.04) with post hoc analysis significant difference between 4th versus 1st quartile (Tukey p value 0.04). Conclusion: In this retrospective cohort study using a large US inpatient database, we identified a significant association between hospital volume and inpatient mortality. Furthermore, plasmapheresis was initiated earlier in the hospital course at higher volume hospitals and provides a potential mechanism for the survival improvement. Disclosures Podoltsev: Ariad: Consultancy; Incyte: Consultancy; Alexion: Consultancy; CTI biopharma/Baxalta: Consultancy. Huntington: Janssen: Consultancy; Pharmacyclics: Honoraria; Celgene: Consultancy, Other: Travel. Zeidan: AbbVie, Otsuka, Pfizer, Gilead, Celgene, Ariad, Incyte: Consultancy, Honoraria; Takeda: Speakers Bureau; Otsuka: Consultancy.

scholarly journals 1280. A Pharmacist-led PrEP Program at the Epicenter of the HIV Epidemic in Atlanta; Our Experience

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S461-S461
Author(s):  
Bradley L Smith ◽  
Allison M Hester ◽  
Valeria D Cantos ◽  
Tiffany R James ◽  
Meredith H Lora
Keyword(s):  
United States ◽  
Primary Care ◽  
The United States ◽  
Post Exposure Prophylaxis ◽  
Provider Education ◽  
Large Hospital ◽  
Hospital System ◽  
Primary Care Clinics ◽  
Hiv Epidemic ◽  
Exposure Prophylaxis

Abstract Background Atlanta, GA ranks third in the nation for highest rates of new HIV diagnoses, disproportionally affecting Black men and women. Pre-exposure prophylaxis (PrEP) is underutilized in this population due to multiple barriers to uptake, including limited access to PrEP delivery programs. The advantages of a primary pharmacy-led PrEP program include: relatively low service fees, perform and assess point-of-care testing, and provide adherence counseling. Similar programs across the United States have been shown to effectively increase PrEP uptake and optimize retention in care. Grady Health System (GHS), the fifth largest public hospital system in the United States, is located at the epicenter of the HIV epidemic: downtown Atlanta. It encompasses 11 different primary care clinics, accounting for 850,000 outpatient visits per year. In August 2018, we launched a developmental pilot of a GHS pharmacy-based tele-PrEP program, aiming to optimize PrEP access for vulnerable populations who would otherwise not be able to obtain it. PrEP services are provided directly to the community and through a consultative support program for all clinical sites within the GHS system. The key pilot interventions included developing a user-friendly electronic medical record (EMR)-based PrEP order sets and brief provider education interventions in 6 GHS primary care clinics, to increase PrEP awareness among non-HIV clinicians. Methods We conducted a retrospective process evaluation of the pilot PrEP program based on the PrEP continuum of care. Results Over 9 months, 95 referrals were received from providers within the GHS clinics. Of the 95 patients referred, 56 (59%) started PrEP. Two patients were started on post-exposure prophylaxis prior to initiation of PrEP. Forty-five patients (81%) remain on PrEP as of April 2019. Six clients were diagnosed with 9 STIs on screening (4 syphilis, 2 gonorrhea, 2 chlamydia, 1 lymphogranuloma venereum). There have been no HIV seroconversions in patients on PrEP. Conclusion Utilizing a pharmacy-based PrEP program to train and support clinical providers in a large, hospital system can facilitate PrEP uptake and retention for patients in primary care. Disclosures All authors: No reported disclosures.

scholarly journals Preterm Birth During the Coronavirus Disease 2019 (COVID-19) Pandemic in a Large Hospital System in the United States

2021 ◽  
Vol 137 (3) ◽  
pp. 403-404 ◽  
Author(s):  
Rachel Wood ◽  
Colleen Sinnott ◽  
Ilona Goldfarb ◽  
Mark Clapp ◽  
Thomas McElrath ◽  
...  
Keyword(s):  
United States ◽  
Preterm Birth ◽  
The United States ◽  
Large Hospital ◽  
Hospital System

scholarly journals Assessment of vitamin B12 deficiency and B12 screening trends for patients on metformin: a retrospective cohort case review

2021 ◽  
pp. bmjnph-2020-000193
Author(s):  
Darby Martin ◽  
Jeet Thaker ◽  
Maria Shreve ◽  
Lois Lamerato ◽  
Kartazyna Budzynska
Keyword(s):  
Retrospective Cohort ◽  
Protective Factor ◽  
Vitamin B12 Deficiency ◽  
Older Age ◽  
Secondary Outcome ◽  
Vitamin B ◽  
Case Review ◽  
Large Hospital ◽  
Hospital System ◽  
B12 Deficiency

ObjectivesOur study investigated the use of vitamin B12 testing in a large cohort of patients on metformin and assesses appropriateness and benefits of screening recommendations for vitamin B12 deficiency.DesignThis retrospective cohort study included insured adult patients who had more than 1 year of metformin use between 1 January 2010 and 1 October 2016 and who filled at least two consecutive prescriptions of metformin to establish compliance. The comparison group was not exposed to metformin. Primary outcome was incidence of B12 deficiency diagnosed in patients on metformin. Secondary outcome was occurrence of B12 testing in the patient population on metformin. Records dated through 31 December 2018 were analysed.SettingLarge hospital system consisting of inpatient and outpatient data base.ParticipantsA diverse, adult, insured population of patients who had more than 1 year of metformin use between 1 January 2010 and 1 October 2016 and who filled at least two consecutive prescriptions of metformin.ResultsOf 13 489 patients on metformin, 6051 (44.9%) were tested for vitamin B12 deficiency, of which 202 (3.3%) tested positive (vs 2.2% of comparisons). Average time to test was 990 days. Average time to test positive for deficiency was 1926 days. Factors associated with testing were linked to sex (female, 47.8%), older age (62.79% in patients over 80 years old), race (48.98% white) and causes of malabsorption (7.11%). Multivariable logistic regression showed older age as the only factor associated with vitamin B12 deficiency, whereas African-American ethnicity approached significance as a protective factor.ConclusionsBased on our study’s findings of vitamin B12 deficiency in patients on metformin who are greater than 65 years old and have been using it for over 5 years, we recommend that physicians consider screening in these populations.

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