Introduction: The purpose of this study was to compare the outcomes of patients hospitalized for diverticulitis based on hospital location (rural or urban). Methods: We identified discharges from the nationwide inpatient sample with a principal diagnosis of diverticulitis (ICD-9 codes 562.11 and 562.13). Patient and hospital characteristics were summarized by hospital location (rural or urban) and differences across hospital location were tested using chi-square tests or t-tests. Outcomes were summarized by hospital location and univariate chi-square tests or t-tests were performed. The outcomes were in-hospital mortality, length of stay, and total hospital charges. We used multivariable logistic regression for in-hospital mortality to calculate adjusted odds ratios for hospital location, adjusting for age, sex, race, Elixhauser comorbidity score, hospital teaching status, and hospital region. We used multivariable linear regression for length of stay and total hospital charge, adjusting for the same variables. Length of stay and total charge were log-transformed for analysis as the original values were extremely right skewed. Results: A total of 243,995 discharges were identified with a principal diagnosis of diverticulitis. Among these patients, 15% were in rural hospitals, and 85% were in urban hospitals. In multivariable analysis, inhospital mortality did not differ significantly by hospital location (p=0.81). After adjusting for covariates in multivariable analysis, length of stay was 8.6% longer in urban than in rural hospitals (p<0.001) and total charges were 73.1% higher in urban than in rural hospitals (p<0.001). If we apply these percentages to the median values of the rural hospitals this equates to a 0.25 day increase and a $9,086 increase in urban hospitals. Conclusion: In an analysis comparing diverticulitis outcomes in rural and urban hospitals, there was no difference in mortality. Length of stay was significantly longer in urban hospitals, and total cost was significantly higher in urban hospitals, both adjusting for patient and hospital characteristics. These data prompt us to further examine the diagnostic testing and interventions which are delivered at urban hospitals that increase cost and extend hospitalization without conferring a survival advantage.Table 1: Outcomes by Hospital Location, Univariate Comparisons
Introduction: Direct Acting Antivirals (DAAs) have dramatically changed the landscape of hepatitis C virus (HCV) treatment. However, a small subset of patients fail to respond to DAA therapy, and become either a non-responder or relapser. We studied the clinical and genetic resistance-associated variants (RAVs) of these patients. Methods: This retrospective analysis looked at the characteristics of patients who failed DAA therapy for treatment of HCV at The Ohio State University, Wexner Medical Center between 2013 and 2016. Data on patient demographics, labs, prior therapy, DAA therapy, side effects, and resistance data were reviewed. Concordance in SVR-12 and SVR-24 in DAA failures was compared using McNemar's Test. Results: A total of 1012 patients with HCV were treated with DAAs. Of these, only 41 (4%) were either relapsers (34; 83%) or non-responders (7; 17%). Cirrhosis was present at the time of treatment in 33 (81%), with median HCV RNA levels of 1,471,012 IU/mL (interquartile range (IQR): 439,410-2,818,776). Genotype (GT) 1a was most common (19), followed by GT1b (10), GT3 (8), GT4 (3) and GT6 (1). The majority of patients were treated with ledipasvir/sofosbuvir (53.7%), followed by sofosbuvir/ribavirin (19.5%) and simeprevir/sofosbuvir (14.6%). Of note, 24.4% of patients were treatment experienced (14.3% of non-responders vs. 26.5% of relapsers, p = 0.66). Treatment duration ranged between 8 to 24 weeks. SVR-12 was achieved in 11 (27%) patients, however, all of them failed SVR at 24 weeks showing poor concordance between SVR-12 and SVR-24 (p < 0.001). Of note, nonstructural protein 5A (NS5A) RAV testing was performed after treatment failure in 6 relapsed patients with probable resistance found in 4 patients. Conclusion: Direct acting antivirals were found to be effective in treating all genotypes of HCV infection. The majority of patients who did not respond to DAA treatment had cirrhosis, high HCV viremia, and GT1a. We found a poor concordance between SVR-12 and SVR-24 in these patients. RAVs are common in patients who fail DAA treatment, although RAV testing was not completed for most patients in our study. This analysis is limited by the small patient data set.
The acuity adjustment metric that correlates most closely with actual medication expense at a large, tertiary care academic medical center was investigated.This evaluation was conducted at the Ohio State University Wexner Medical Center. All inpatient discharges between July 1, 2012, and March 31, 2013, were included in this study. Patient medical and financial records were used to obtain the diagnosis-related group (DRG) codes and total medication cost for each patient discharge. The primary DRG for each patient was then used to assign the corresponding relative weight (RW) and pharmacy intensity weight (PIW). The correlation between actual and predicted medication expenditure was determined for every DRG for both RW and PIW. Since this compares cost at the DRG level, RW and PIW were used as markers for case-mix index (CMI) and pharmacy intensity score (PIS), respectively.At this single institution, medication cost per discharge was more strongly correlated with PIW (as a marker for PIS) than with RW (as a marker for CMI). Extrapolating these data to hospital-specific values, the results suggest that PIS is more strongly correlated with overall medication expense than CMI and therefore a better adjustment metric for monitoring medication expense over time.A single-institution study demonstrated that PIW was more strongly correlated than RW with actual medication expenditure. PIS may be a more accurate acuity metric than CMI for predicting changes in drug expense over time.
Background: Compared with patients who undergo pancreatic surgery for chronic pancreatitis and malignancy, patients with pancreatic cystic lesions (PCLs) generally have normal adjacent pancreatic parenchyma. There is a paucity of literature evaluating new-onset diabetes mellitus (NODM) following PCL resection. We sought to characterize the incidence and risk factors associated with NODM following partial pancreatectomy for PCLs. Methods: We utilized the IBM MarketScan Database (2012-2018) to identify all non-diabetic adult patients who underwent elective partial pancreatectomy for PCLs. Rigorous stepwise exclusion criteria were applied to identify patients without other pancreatic disease. We performed time-to-event analyses using Kaplan-Meier curves and multivariable Cox proportional hazards regression to define the incidence and risk factors associated with postoperative NODM. Findings: Among 311 patients with PCLs who underwent partial pancreatectomy, the overall risk of NODM was 9.1% (95% CI 6.3-12.9%), 15.1% (95% CI 11.3-20.2%), and 20.2% (95% CI 15.3-26.4%) at six, 12 and 24 months, respectively. Multivariable analysis revealed that older age (55-64 years, adjusted Hazard Ratio (aHR) 1.97, 95% CI 1.04-3.72 vs. 18-54 years), obesity (aHR 2.63, 95% CI 1.35-5.12), hypertension (aHR 1.79, 95% CI 1.01-3.17), and cardiovascular disease (aHR 2.54, 95% CI 1.02-6.28) were independent predictors of postoperative NODM. Rates of NODM were similar following distal pancreatectomy versus pancreaticoduodenectomy. Interpretation: Within two years, approximately one in five patients will develop NODM following partial pancreatectomy for PCLs. Those with advanced age, metabolic syndrome features, and/or cardiovascular disease may benefit from preoperative counselling for risk-reduction and intensive postoperative monitoring, education, and treatment strategies for DM. Funding: National Center for Advancing Translational Sciences, award number UL1TR002733.Declaration of Interests: None of the authors have any conflicts of interest or financial ties to disclose related to the current study.Ethics Approval Statement: This database is a publicly available population-based dataset. As such, the study was exempt from approval by the Ohio State University Institutional Review Board.
Evidence guiding inpatient management of buprenorphine is lacking—this retrospective cohort study evaluated the clinical impact of hospital continuation versus discontinuation of buprenorphine at an academic medical center. The primary outcome was inpatient oral morphine equivalents (OME). Secondary outcomes included patient pain levels, functional assessment, and hospital length of stay. One hundred thirty-one patients (74 continued buprenorphine, 57 discontinued) were included in the analysis. Median OME were significantly lower among patients continued on buprenorphine versus discontinued (11 mg vs 103 mg, p < 0.001), as was maximum 24-hour opioid utilization (60 mg vs 240 mg, p < 0.001) and 24-hour pre-discharge utilization (10 mg vs 128 mg, p < 0.001). Median pain levels were similar between groups at the time of admission (8 in each group, p = 0.48), discharge (7 in each group, p = 0.26), and over the first 7 days of hospitalization (7 vs 8, p = 0.08). Hospital length of stay was similar between groups (5 days in each group, p > 0.99). Failure to reinitiate buprenorphine occurred in 31/57 patients (54.4%) in the discontinuation group. Hospital buprenorphine continuation is associated with reduced opioid requirements, while not significantly impacting pain levels, functionality, or length of admission. Failure to reinitiate buprenorphine was common and may have negative implications for addiction treatment.
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