Impact of Underlying Congestive Heart Failure on In-Hospital Outcomes in Patients with Septic Shock

Purpose: Septic shock (SS) manifests with profound circulatory and cellular metabolism abnormalities and has a high in-hospital mortality (25%-50%). Congestive heart failure (CHF) patients have underlying circulatory dysfunction and compromised cardiac reserve that may place them at increased risk if they develop sepsis. Outcomes in patients with CHF who are admitted with SS have not been well studied. Materials and Method: Retrospective cross sectional secondary analysis of the Nationwide Readmission Database (NRD) for 2016 and 2017. ICD-10 codes were used to identify patients with SS during hospitalization, and then the cohort was dichotomized into those with and without an underlying diagnosis of CHF. Results: Propensity match analyses were performed to evaluate in-hospital mortality and clinical cardiovascular outcomes in the 2 groups. Cardiogenic shock patients were excluded from the study. A total of 578,629 patients with hospitalization for SS were identified, of whom 19.1% had a coexisting diagnosis of CHF. After propensity matching, 81,699 individuals were included in the comparative groups of SS with CHF and SS with no CHF. In-hospital mortality (35.28% vs 32.50%, P < .001), incidence of ischemic stroke (2.71% vs 2.53%, P = .0032), and acute kidney injury (69.9% vs 63.9%, P = .001) were significantly higher in patients with SS and CHF when compared to those with SS and no CHF. Conclusions: This study identified CHF as a strong adverse prognosticator for inpatient mortality and several major adverse clinical outcomes. Study findings suggest the need for further investigation into these findings’ mechanisms to improve outcomes in patients with SS and underlying CHF.

Gender-Specific Outcomes after Percutaneous Left Atrial Appendage Closure - A Nationwide Readmission Database Analysis

Background: Thromboembolism-associated stroke is the most feared complication of Atrial fibrillation (AF). Percutaneous left atrial appendage closure (pLAAC) is indicated for stroke prevention in patients with AF who can’t tolerate long-term anticoagulation. We aim to study gender differences in peri-procedural and readmissions outcomes in pLAAC patients. Methods: Using the national readmission database from January 2016 to December 2018, AF patients undergoing the pLAAC procedure were identified. We used multivariate logistic regression analyses and time-to-event Cox regression analyses to conduct the study. Propensity matching with the Greedy method was done for the accuracy of results. Result: 28,819 patients were included in our study. Among them 11,946 (41.5%) were women and 16,873 (58.6%) were men. The mean age of overall population was 76.1 ± 8.5 years, with women ~ 1 year older than men. The overall rate of complications was higher in women (8.6% vs 6.6%, P<0.001), primarily driven by bleeding-related complications i.e., Major bleed (OR: 1.32 95% CI: 1.03-1.69, p=0.029), blood transfusion (OR: 1.45, 95% CI: 1.06-1.97, p=0.019) and cardiac tamponade (OR: 1.80, 95% CI: 1.13-2.89, p=0.014). Women had two times higher peri-procedural ischemic stroke. There was no difference in peri-procedural mortality. Women remained at 20% and 13% higher risk for readmission at 30 days and 6 months of discharge. Conclusion: Women had higher peri-procedural complications and were at higher risk of readmissions at 30 days and six months. However, there was no difference in mortality during the index hospitalization. Further studies are necessary to determine causality.

Risk of 30-day Readmission after Knee or Hip Replacement in Rheumatoid Arthritis and Osteoarthritis by non-Medicare and Medicare Payer Status

Objective To determine the indication and risk of 30-day rehospitalization after hip or knee replacement among rheumatoid arthritis (RA) and osteoarthritis (OA) by Medicare and non-Medicare status. Methods Using the Nationwide Readmission Database (2010-2014), we defined an Index hospitalization as an elective hospitalization with a principal procedure of total hip or knee replacement among adults aged ≥18 years. Primary payer was categorized as Medicare or non- Medicare. Survey logistic regression provided the odds of 30-day rehospitalization in RA relative to OA. We calculated the rates for principal diagnoses leading to rehospitalization. Results Overall, 3.53% of 2,190,745 index hospitalization had a 30-day rehospitalization. Patients with RA had a higher adjusted risk of rehospitalization after TKR (Odds Ratio [OR], 1.11; 95% Confidence Interval [CI], 1.02 to 1.21) and THR (OR, 1.39; 95% CI, 1.19 to 1.62). Persons with RA and OA did not differ with respect to rates of infections, cardiac events, or postoperative complications leading to the rehospitalization. After TKR, RA patients with Medicare had a lower VTE risk (OR, 0.58;95% CI, 0.58 to 0.88) while post-THR those with RA had a greater VTE risk (OR, 2.41;95% CI, 1.04 to 5.57). Conclusion RA patients had a higher 30-day rehospitalization than OA after TKR and THR regardless of payer type. While infections, postoperative complications, cardiac did not differ, there was a significant difference in venous thromboembolism as the rehospitalization's principal diagnosis.

Costs and predictors of early readmissions in patients with Infective Endocarditis. Utilizing the Nationwide Readmission Database

BACKGROUND: There have been previous studies detailing the variables involved in readmissions in patients with a primary admission diagnosis of infective endocarditis – however those studies were done prior to the 2015 change in AHA guidelines and introduction to ICD-10 codes. OBJECTIVES: The aim of this study was to describe the frequency, causes, factors, and costs associated with infective endocarditis encounters. METHODS: Utilizing the 2017 national readmission database (NRD), we identified all patients that were admitted with infective endocarditis. These patients were evaluated for the rates, predictors, and costs of unplanned 30 days readmissions. Weighted analysis was performed to obtain nationally representative data. RESULTS: 56,357 patients were identified to have been admitted with a diagnosis of infective endocarditis of whom 13,004 patients (23%) were readmitted within 30 days of the index discharge. The most common causes of readmission were septicemia (15.1%), endocarditis and endocardial disease (10.5%), heart failure (9.5%), and complication of cardiovascular device, implant or graft, initial encounter (5.6%). Data showed that there were certain comorbidities that resulted in a higher risk of being readmitted, these include chronic kidney disease, COPD, tobacco use, and hepatic failure. Cost of readmissions per patient was approximately $22,059 (IQR $11,630 - $49,964). CONCLUSIONS: Thirty-day unplanned readmissions remain a significant issue affecting nearly 1 in 6 patients with infective endocarditis. This is associated with significant mortality and financial burden. Multi-disciplinary approach may help decrease readmissions, reduce complications, and improve overall outcomes as well as the overall quality of life of our patients.