Despite limited evidence to support its efficacy, use of pulmonary artery catheter (PAC), a relatively expensive medical device, for monitoring clinical status and guiding therapeutic interventions, has become standard of care in many settings, and especially during and after cardiac surgery. We examined the prevalence and predictors of PAC use and its association with hospitalization charges among cardiac surgery patients generally and for each selected subgroup of high-risk or complex surgical procedures. We conducted an analysis on 1,442,528 records from the National Inpatient Sample (1999–2019) that included cardiac surgery patients ≥18 years of age. Subgroups were categorized based on the presence of specific disorders like tricuspid or mitral valve disease, pulmonary hypertension, heart failure, or cardiac surgery combinations. Multivariable regression models were constructed to assess predictors of PAC use as well as PAC use as a predictor of loge hospitalization charges controlling for patient and hospital characteristics. Based on International Classification of Diseases procedure codes, PAC use was prevalent among 7.15 % of cardiac surgery hospitalizations, and hospitalization charges were estimated at $191,345, with no differences according to PAC use. Overall, being female, having Charlson comorbidity index (CCI) > 0, and non-payer (versus Medicare) status were independently associated with PAC use. Among the subgroup with the selected conditions, being female, having CCI>0, and being a Medicaid (versus Medicare) recipient were independently associated with PAC use, whereas elective admission was inversely related to PAC use. Among the subgroup without the selected conditions, having a CCI >0, elective admission, and non-payer (vs. Medicare) status were independently associated with PAC use. PAC use was not independently related to hospitalization charges overall or among subgroups. In conclusion, approximately 7 % of cardiac surgery hospitalizations received a PAC, with no differences in charges according to PAC use and disparities in PAC use driven by sex, elective admission, CCI and health insurance status. Large randomized trials are required to characterize the safety, efficacy, and cost-effectiveness of PAC use among distinct groups of patients undergoing cardiac surgery.

BACKGROUND AND OBJECTIVE:Unnecessary care delays for hospitalized patients increase the risk of hospital-related complications and drive up health care costs. While health systems focus on reducing the length of stay of hospitalized patients, not many studies looked at specific causes of the care delays that prolong length of stay. In this study, we sought to systematically identify and categorize the various care delays that contribute to prolonged length of stay on a hospital medicine service. METHODS:We conducted a retrospective observational study looking at all inpatient encounters to the hospitalist service (N = 6633) for the fiscal year 2021. Observation status, COVID-19 positive, and other services' discharged patients were excluded (N = 2849) leaving 3784 eligible encounters. The resulting 5% stratified random sample accounted for 190 encounters accounting for a total of 1152 patient-days. Using a standardized data extraction tool, a day-by-day review of the sample encounters was performed for all care delays. These care delays were categorized into specific groups (System, Discharge, Provider, Patient/Family, or Consultant related) and subgroups based on predetermined criteria. RESULTS:The stratified sample was found to be comparable to the total patient population, with no statistically significant differences in key demographic and clinical metrics. About 30% of all patient-days had a care delay; 33% of these delays were attributable to system delays internal to the hospital such as waiting for imaging/procedures; 28% of delays were due to discharge barriers, driven overwhelmingly by a lack of available post-acute care beds, and about 20% of delays were attributable to the provider. CONCLUSION:Our study systematically looked at care delays that led to prolonged hospital length of stay. Most of these care delays were caused by either wait times for procedures and imaging studies or by a lack of post-acute care bed availability. Hospitals and health systems can use this approach to better determine which systemic changes are likely to be the most effective at reducing length of stay.

Neurofilament light chain (NfL) is a neuron-specific structural protein released into the extracellular space, including body fluids, upon neuroaxonal damage. Despite evidence of a link in neurological disorders, few studies have examined the association of serum NfL with mortality in population-based studies. Data from the National Health and Nutrition Survey were utilized including 2,071 Non-Hispanic White, Non-Hispanic Black and Hispanic adult participants and adult participants of other ethnic groups (20–85 years) with serum NfL measurements who were followed for ≤ 6 years till 2019. We tested the association of serum NfL with mortality in the overall population and stratified by sex with the addition of potential interactive and mediating effects of cardio-metabolic risk factors and nutritional biomarkers. Elevated serum NfL levels (above median group) were associated with mortality risk compared to the below median NfL group in the overall sample (P = 0.010), with trends observed within each sex group (P < 0.10). When examining Loge NfL as a continuum, one standard deviation of Loge NfL was associated with an increased mortality risk (HR = 1.88, 95

Introduction:Workplace violence (WPV) is increasing in healthcare and negatively impacts healthcare worker outcomes. De-escalation training for healthcare workers is recommended to reduce WPV from patients and visitors. Hospitalists may be at high risk for WPV, but the magnitude of WPV and the impact of de-escalation training among hospitalists is not known. Methods:We investigated the baseline prevalence of WPV experienced by 37 hospitalists at a single center. After an in-person de-escalation training, we measured hospitalists' self-reported "Confidence in Coping with Patient Aggression" using a validated scale (score range 10-110). Results:In the 12 months before de-escalation training, 86.5% of participants reported at least one form of WPV: 83.8% verbal abuse, 29.7% racial abuse, 18.9% physical violence, and 16.2% sexual abuse. The mean confidence score increased significantly from pre-training (43.2) to immediately after training (68.5) and remained significantly elevated at three months (57.2), six months (60.2), and after 12 months (59.9) (all P < 0.05; Ptrend <0.05). Conclusion:Hospitalists are at high risk for WPV. Structured in-person de-escalation training may provide the sustained ability for hospitalists to cope with WPV.

Background: Monoclonal antibody (mAb) treatment for coronavirus disease 2019 (COVID-19) has been underutilized due to logistical challenges, lack of access, and variable treatment awareness among patients and health-care professionals. The use of telehealth during the pandemic provides an opportunity to increase access to COVID-19 care.Methods: This is a single-center descriptive study of telehealth-based patient self-referral for mAb therapy between March 1, 2021, and October 31, 2021, at Baltimore Convention Center Field Hospital (BCCFH).Results: Among the 1001 self-referral patients, the mean age was 47, and most were female (57%). White (66%), and had a primary care provider (PCP) (62%). During the study period, self-referrals increased from 14/mo in March to 427 in October resulting in a 30-fold increase. Approximately 57% of self-referred patients received a telehealth visit, and of those 82% of patients received mAb infusion therapy. The median time from self-referral to onsite infusion was 2 d (1-3 IQR).Discussion: Our study shows the integration of telehealth with a self-referral process improved access to mAb infusion. A high proportion of self-referrals were appropriate and led to timely treatment. This approach helped those without traditional avenues for care and avoided potential delay for patients seeking referral from their PCPs.

Valerie Press reports receiving consulting fees from Humana and Vizient for patient education and care transition interventions. The remaining authors declare no conflict of interest.

Background Over one in five Medicare patients discharged to skilled nursing facilities (SNFs) are re-hospitalized within 30 days of discharge. Poor communication between the hospital and SNF upon hospital discharge is frequently cited as the most common cause of readmission. Aim The goal of this program was to assess the ability of a weekly post-discharge hospitalist led virtual rounding program to augment the written discharge summary sent to SNFs. Setting Two academic hospitals and six SNFs in Baltimore, MD. Participants Hospitalists and medical directors or directors of nursing from the partner SNF. Program Description During weekly encounters, the hospitalist and SNF providers discussed the clinical status, discharge medications, treatment plan, and follow-up care of all discharged patients. The intervention took place from July 2021 to December 2021. Program Evaluation During the study, 544 patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists identified clinically significant errors in 124 discharge summaries. A survey of participating hospitalists and SNF medical and nursing leadership indicated the intervention was thought to improve care transitions. Discussion Our innovation was successful in identifying errors in discharge summaries and was thought to improve the transition of care by participating SNF and hospitalist providers.

Treatment regimens combining glucocorticoids with cyclophosphamide or rituximab or both are used to induce remission in ANCA-associated glomerulonephritis (ANCA-GN). There is a paucity of data on the efficacy and safety of these regimens in elderly patients with ANCA-GN. This study aimed to examine outcomes and adverse events in elderly AAV patients with three induction regimens: cyclophosphamide (CYC), cyclophosphamide and rituximab (CYC + RTX), and rituximab (RTX). This single-center retrospective cohort study included patients 60 years and older diagnosed with ANCA-GN. Baseline characteristics and outcomes across several clinical parameters were recorded and compared for significance using Kruskal–Wallis test, Chi-squared test, Fisher exact test, univariate, and multivariate logistic regression as appropriate. Cox proportional hazard regression model was used for survival analysis. Seventy-five patients were included. The mean (SD) age at diagnosis was 70 (± 6) years. The mean (SD) follow-up duration was 5.17 (± 3.47) years. Remission induction therapy with glucocorticoids plus CYC was used in 25 patients, glucocorticoids plus CYC and RTX in 12 patients, and glucocorticoids plus RTX in 38 patients. RTX-treated patients had a higher baseline estimated glomerular filtration ratio (eGFR) (p = 0.00009). High remission rates were achieved in all groups (100

To examine associations of pulmonary artery catheter (PAC) use with in-hospital death and hospital length of stay (days) overall and within subgroups of hospitalized cardiac surgery patients. Secondary analyses of 1999–2019 National Inpatient Sample data were performed using 969,034 records (68% male, mean age: 65 years) representing adult cardiac surgery patients in the United States. A subgroup of 323,929 records corresponded to patients with congestive heart failure, pulmonary hypertension, mitral/tricuspid valve disease and/or combined surgeries. We evaluated PAC in relation to clinical outcomes using regression and targeted maximum likelihood estimation (TMLE). Hospitalized cardiac surgery patients experienced more in-hospital deaths and longer stays if they had ≥ 1 subgroup characteristics. For risk-adjusted models, in-hospital deaths were similar among recipients and non-recipients of PAC (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.96, 1.12), although PAC was associated with more in-hospital deaths among the subgroup with congestive heart failure (OR 1.14, 95% CI 1.03, 1.26). PAC recipients experienced shorter stays than non-recipients (β = − 0.40, 95% CI − 0.64, − 0.15), with variations by subgroup. We obtained comparable results using TMLE. In this retrospective cohort study, PAC was associated with shorter stays and similar in-hospital death rates among cardiac surgery patients. Worse clinical outcomes associated with PAC were observed only among patients with congestive heart failure. Prospective cohort studies and randomized controlled trials are needed to confirm and extend these preliminary findings.

We applaud Wietlisbach and colleagues for highlighting the silver lining in the dark clouds of the COVID-19 pandemic.1 Their qualitative study based on 4 internal medicine (IM) residency programs in the Northeast United States suggests that IM residents adjusted quickly to the disruption and changes brought on by COVID-19 and focused on resiliency and well-being during the pandemic. Our own experience at a large IM residency program at Johns Hopkins Bayview Medical Center suggested that, although COVID-19 had a predominantly negative effect on the well-being of the residents, it also presented an incredible learning opportunity. Forty IM residents were contacted as part of a larger survey to monitor the stress and well-being of staff during COVID-19 at Johns Hopkins Bayview Medical Center between October and December 2020, out of which 18 (45%) completed the survey. Survey measures included Patient Health Questionnaire-2, Generalized Anxiety Disorder-7, and modified Maslach Burnout Inventory. In addition, residents were asked about the satisfaction of their educational experience.Survey results showed that 17% of the residents had significant depressive symptoms and sleep disturbances, while 25% endorsed moderate to severe anxiety symptoms. More than 70% residents felt burned out, and 22% indicated that they felt burned out and callous toward their work on a daily basis. Ninety-four percent of residents indicated that their training was significantly impacted by COVID-19. Sixty-seven percent had to miss their didactic training due to work demands. Thirty-three percent had to change their core or elective rotations. On the positive side, 50% of the residents indicated that they learned new skills during COVID-19 that contributed to their professional growth. Some of the comments from residents were: “Now on call as an intern,” “Taking on more shifts on my scheduled days off,” “Type of cases seen are limited by COVID,” “Zoom didactic sessions are not as effective as in person,” and “Less mentorship and teaching from upper residents and faculty.”In contrast to the Wietlisbach study, our survey suggests that the residents were less enthusiastic about the technological innovations in didactics and training and longed to go back to the pre-COVID-19 normal. However, we also found a strong focus of resiliency by the residents, with 61% of the sample scoring >6 on the 2-item Connor-Davidson Resilience Scale. We agree with Wietlisbach and colleagues that COVID-19 can be a catalyst in the transformation of graduate medical education.2

The 2010 Patient Protection and Affordable Care Act was aimed at reducing healthcare costs, improving healthcare quality, and expanding health insurance coverage among uninsured individuals in the United States. We examined trends in the utilization of radiation therapies and stereotactic radiosurgery before and after its implementation among U.S. adults hospitalized with brain metastasis. Interrupted time-series analyses of data on 383,934 Nationwide Inpatient Sample hospitalizations (2005-2010 and 2011-2013) were performed, whereby yearly and quarterly cross-sectional data were evaluated and Affordable Care Act implementation was considered the main exposure variable, stratifying by patient and hospital characteristics. Overall, we observed a declining trend in radiation therapy over time, with an upward shift post-Affordable Care Act. A downward shift in radiation therapy post-Affordable Care Act was observed among Northeastern and rural hospitals, whereas an upward shift was noted among specific patient (females, 18-39 or ≥ 65 years of age, Charlson Comorbidity Index (CCI) ≥10, non-elective admissions, Medicare, self-pay, no pay or other insurance) and hospital (Midwestern, Western, non-teaching urban) subgroups. Stereotactic radiosurgery utilization among recipients of radiation therapy increased over time among Hispanics, elective admissions, and rural hospitals, whereas post-Affordable Care Act was associated with increased stereotactic radiosurgery among African-Americans and non-elective admissions and decreased stereotactic radiosurgery among elective admissions, and rural hospitals. Whereas hospitalized adults in the United States utilized less radiation therapy over the nine-year period, utilization of radiation therapy, in general, and stereotactic radiosurgery, in particular, were not consistent among distinct subgroups defined by patient and hospital characteristics, with some traditionally underserved populations more likely to receive healthcare services post-Affordable Care Act. The Affordable Care Act may be helpful at closing the gap in access to technological advances such as stereotactic radiosurgery for treating brain metastases.

There is a paucity of data on the mental health impact of the Coronavirus disease 2019 (COVID-19) pandemic on United States (US) healthcare workers (HCWs) after the first surge in the spring of 2020. To determine the impact of the pandemic on HCWs, and the relationship between HCW mental health and demographics, occupational factors, and COVID-19 concerns. Cross-sectional survey in an urban medical center (September–November 2020) in Baltimore, MD, in the United States. A total of 605 HCWs (physicians, nurse practitioners, nurses, physician assistants, patient care technicians, respiratory therapists, social workers, mental health therapists, and case managers). Measures of mental health (Patient Health Questionnaire-2, Generalized Anxiety Disorder-7, PROMIS Sleep Disturbance 4a, Impact of Event Scale-Revised, Maslach Burnout Inventory-2 item, Connor-Davidson Resilience Scale-2 item), demographics, occupational factors, and COVID-19 related concerns. Fifty-two percent of 1198 HCWs responded to the survey and 14.2% reported depression, 43.1% mild or higher anxiety, 31.6% sleep disturbance, 22.3% posttraumatic stress symptoms, 21.6% depersonalization, 46.0% emotional exhaustion, and 23.1% lower resilience. Relative to HCWs providing in-person care to COVID-19 infected patients none of their working days, those doing so all or most days were more likely to experience worse depression (adjusted odds ratio, 3.9; 95% CI, 1.3–11.7), anxiety (aOR, 3.0; 95% CI, 1.4–6.3), possible PTSD symptoms (aOR, 2.6; 95% CI, 1.1–5.8), and higher burnout (aOR, 2.6; 95% CI, 1.1–6.0). Worse mental health in several domains was associated with higher health fear (aORs ranged from 2.2 to 5.0), job stressors (aORs ranged from 1.9 to 4.0), perceived social stigma/avoidance (aORs ranged from 1.8 to 2.9), and workplace safety concerns (aORs ranged from 1.8 to 2.8). US HCWs experienced significant mental health symptoms eight months into the pandemic. More time spent providing in-person care to COVID-19-infected patients and greater COVID-19-related concerns were consistently associated with worse mental health.

Background During the initial wave of COVID-19 hospitalizations, care delivery and workforce adaptations were rapidly implemented. In response to subsequent surges of patients, institutions have deployed, modified, and/or discontinued their workforce plans. Objective Using rapid qualitative methods, we sought to explore hospitalists’ experiences with workforce deployment, types of clinicians deployed, and challenges encountered with subsequent iterations of surge planning during the COVID-19 pandemic across a collaborative of hospital medicine groups. Approach Using rapid qualitative methods, focus groups were conducted in partnership with the Hospital Medicine Reengineering Network (HOMERuN). We interviewed physicians, advanced practice providers (APP), and physician researchers about (1) ongoing adaptations to the workforce as a result of the COVID-19 pandemic, (2) current struggles with workforce planning, and (3) evolution of workforce planning. Key Results We conducted five focus groups with 33 individuals from 24 institutions, representing 52% of HOMERuN sites. A variety of adaptations was described by participants, some common across institutions and others specific to the institution’s location and context. Adaptations implemented shifted from the first waves of COVID patients to subsequent waves. Three global themes also emerged: (1) adaptability and comfort with dynamic change, (2) the importance of the unique hospitalist skillset for effective surge planning and redeployment, and (3) the lack of universal solutions. Conclusions Hospital workforce adaptations to the COVID pandemic continued to evolve. While few approaches were universally effective in managing surges of patients, and successful adaptations were highly context dependent, the ability to navigate a complex system, adaptability, and comfort in a chaotic, dynamic environment were themes considered most critical to successful surge management. However, resource constraints and sustained high workload levels raised issues of burnout.

In response to the coronavirus disease (COVID-19) pandemic, the State of Maryland established a 250-bed emergency response field hospital at the Baltimore Convention Center to support the existing health care infrastructure. To operationalize this hospital with 65 full-time equivalent clinicians in less than 4 weeks, more than 300 applications were reviewed, 186 candidates were interviewed, and 159 clinicians were credentialed and onboarded. The key steps to achieve this undertaking involved employing multidisciplinary teams with experienced personnel, mass outreach, streamlined candidate tracking, pre-interview screening, utilizing all available expertise, expedited credentialing, and focused onboarding. To ensure staff preparedness, the leadership developed innovative team models, applied principles of effective team building, and provided "just in time" training on COVID-19 and non-COVID-19-related topics to the staff. The leadership focused on staff safety and well-being, offered appropriate financial remuneration, and provided leadership opportunities that allowed retention of staff.

BACKGROUND:The incidences of invasive mechanical ventilation and non-invasive ventilation among patients with non-ST segment elevation myocardial infarction and associated prognosis are not well characterized. METHODS:We conducted a retrospective cohort study of patients with admission diagnosis of non-ST segment elevation myocardial infarction using the US National Inpatient Sample database between 2002-2014. The exposure variable was invasive mechanical ventilation or non-invasive ventilation within 24 h of admission, compared to no respiratory support. The primary outcome was in-hospital mortality. We determined the association between respiratory support and mortality using Cox proportional hazard models. RESULTS:A total of 4,152,421 non-ST segment elevation myocardial infarction hospitalizations were identified, among whom 1.3% required non-invasive ventilation and 1.9% required invasive mechanical ventilation. Non-invasive ventilation use increased over time (0.4% in 2002 to 2.4% in 2014, p<0.001) while there was no definite trend in invasive mechanical ventilation use. Revascularization was lower for non-ST segment elevation myocardial infarction hospitalizations including invasive mechanical ventilation (23.9%) and non-invasive ventilation (14.5%) compared to 36.5% of those without respiratory support (p<0.001). In-hospital mortality was 3.1% for non-ST segment elevation myocardial infarction without respiratory support compared to 9.2% with non-invasive ventilation (adjusted hazard ratio 1.86, 95% confidence interval 1.74-1.98) and 37.2% with invasive mechanical ventilation (adjusted hazard ratio 3.03, 95% confidence interval 2.88-3.19). Mortality for non-ST segment elevation myocardial infarction-non-invasive ventilation is improving over time while mortality for non-ST segment elevation myocardial infarction-invasive mechanical ventilation is increasing over time. CONCLUSION:Mechanical respiratory support in non-ST segment elevation myocardial infarction is used in an important minority of cases, is increasing and is independently associated with mortality. Studies of the optimal management of acute coronary syndrome complicated by respiratory failure are needed to improve outcomes.

ABSTRACT Objective This study aimed to examine patterns of sleep disorders among hospitalized adults 65 years and older as related to Parkinson’s disease (PD) status and to evaluate sex differences in the associations between PD with sleep disorders. Methods A cross-sectional study was conducted using 19,075,169 hospital discharge records (8,169,503 men and 10,905,666 women) from the 2004–2014 Nationwide Inpatient Sample databases. PD and sleep disorder diagnoses were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification coding. Logistic regression models were constructed for each sleep disorder as a correlate of PD status; adjusted odds ratios (aOR) with their 95% confidence intervals (CIs) were calculated taking into account patient and hospital characteristics. Results Period prevalences of PD and sleep disorder were estimated to be 2.1% and 8.1%, respectively. Most sleep disorder types, with the exception of sleep-related breathing disorders, were positively associated with PD diagnosis. Statistically significant interactions by sex were noted for associations of insomnia (men: aOR = 1.29, 95% CI = 1.24–1.36; women: aOR = 1.17, 95% CI = 1.12–1.22), parasomnia (men: aOR = 3.74, 95% CI = 3.44–4.07; women: aOR = 2.69, 95% CI = 2.44–2.96), sleep-related movement disorder (men: aOR = 1.09, 95% CI = 1.07–1.11; women: aOR = 1.22, 95% CI = 1.20–1.25), and any sleep disorder (men: aOR = 1.06, 95% CI = 1.05–1.08; women: aOR = 1.15, 95% CI = 1.13–1.17) with PD status. Conclusions Overall, hospitalized men are more likely to experience PD with insomnia or parasomnia, whereas hospitalized women are more likely to experience PD with sleep-related movement disorder or any sleep disorder. Prospective cohort studies are needed to replicate these cross-sectional findings.

The purpose of this study was to compare hospitalization outcomes among US inpatients with brain metastases who received stereotactic radiosurgery (SRS) and/or non-SRS radiation therapies without neurosurgical intervention. A cross-sectional study was conducted whereby existing data on 35,199 hospitalization records (non-SRS alone: 32,981; SRS alone: 1035; SRS + non-SRS: 1183) from 2005 to 2014 Nationwide Inpatient Sample were analyzed. Targeted maximum likelihood estimation and Super Learner algorithms were applied to estimate average treatment effects (ATE), marginal odds ratios (MOR) and causal risk ratio (CRR) for three distinct types of radiation therapy in relation to hospitalization outcomes, including length of stay (‘ ≥ 7 days’ vs. ‘ < 7 days’) and discharge destination (‘non-routine’ vs. ‘routine’), controlling for patient and hospital characteristics. Recipients of SRS alone (ATE = − 0.071, CRR = 0.88, MOR = 0.75) or SRS + non-SRS (ATE = − 0.17, CRR = 0.70, MOR = 0.50) had shorter hospitalizations as compared to recipients of non-SRS alone. Recipients of SRS alone (ATE = − 0.13, CRR = 0.78, MOR = 0.59) or SRS + non-SRS (ATE = − 0.17, CRR = 0.72, MOR = 0.51) had reduced risks of non-routine discharge as compared to recipients of non-SRS alone. Similar analyses suggested recipients of SRS alone had shorter hospitalizations and similar risk of non-routine discharge when compared to recipients of SRS + non-SRS radiation therapies. SRS alone or in combination with non-SRS therapies may reduce the risks of prolonged hospitalization and non-routine discharge among hospitalized US patients with brain metastases who underwent radiation therapy without neurosurgical intervention.

Despite its public health significance, TBI management across US healthcare institutions and patient characteristics with an emphasis on utilization and outcomes of TBI-specific procedures have not been evaluated at the national level. We aimed to characterize top 10 procedure codes among hospitalized adults with TBI as primary diagnosis by injury severity. A Cross-sectional study was conducted using 546, 548 hospitalization records from the 2004 to 2014 Nationwide Inpatient Sample were analyzed. Data elements of interest included injury, patient, hospital characteristics, procedures, in-hospital death and length of stay. Ten top procedure codes were "Closure of skin and subcutaneous tissue of other sites", "Insertion of endotracheal tube", "Continuous invasive mechanical ventilation for less than 96 consecutive hours", "Venous catheterization (not elsewhere classified)", "Continuous invasive mechanical ventilation for 96 consecutive hours or more", "Transfusion of packed cells", "Incision of cerebral meninges", "Serum transfusion (not elsewhere classified)", "Temporary tracheostomy", and "Arterial catherization". Prevalence rates ranged between 3.1% and 15.5%, with variations according to injury severity and over time. Whereas "Closure of skin and subcutaneous tissue of other sites" was associated with fewer in-hospital deaths and shorter hospitalizations, "Temporary tracheostomy" was associated with fewer in-hospital deaths among moderate-to-severe TBI patients, and "Continuous invasive mechanical ventilation for less than 96 consecutive hours" was associated with shorter hospitalizations among severe TBI patients. Other procedures were associated with worse outcomes. Nationwide, the most frequently reported hospitalization procedure codes among TBI patients aimed at homeostatic stabilization and differed in prevalence, trends, and outcomes according to injury severity.

Background: The 2010 Affordable Care Act aimed at reducing healthcare costs, improving healthcare quality and expanding health insurance coverage among uninsured individuals in the United States. We examined trends in utilization of radiation therapies and stereotactic radiosurgery before and after its implementation among U.S. adults hospitalized with brain metastasis. Methods: Interrupted time-series analyses of data on 383934 2005-2014 Nationwide Inpatient Sample hospitalizations were performed, whereby yearly and quarterly cross-sectional data were evaluated and Affordable Care Act implementation was considered the main exposure variable, stratifying by patient and hospital characteristics. Results: We observed consistently declining trends in radiation therapy over time and post-Affordable Care Act status with variability in level of utilization among specific sub-groups. Stereotactic radiosurgery prevalence increased over time among Hispanics, elective admissions, Midwestern hospitals, non-teaching hospitals and hospitals with medium bed size. Post-Affordable Care Act was associated with increased stereotactic radiosurgery prevalence among African-Americans, non-elective and weekend admissions, with changes in slope in the context of weekend admissions and hospitals with large bed size. Conclusions: Whereas hospitalized adults in the United States utilized less radiation therapy and slightly more stereotactic radiosurgery over the ten-year period, utilization levels and trends were not consistent among distinct sub-groups defined by patient and hospital characteristics, with some traditionally underserved populations more likely to receive healthcare services post-Affordable Care Act implementation. The Affordable Care Act may be helpful at reducing the need for radiation therapy and closing the gap in access to technological advances such as stereotactic radiosurgery for treating brain metastases.

Background: Management of patients with syncope lacks standardization. We sought to assess regional variation in hospitalization rates and resource utilization of patients with syncope. Methods: We identified adults with syncope using the Nationwide Emergency Department Sample from years 2006 to 2014. Demographics and comorbidity characteristics were compared across geographic regions in the US. Multiple regression was conducted to compare outcomes. Results: 9,132,176 adults presented with syncope. Syncope in the Northeast (n = 1,831,889) accounted for 20.1% of visits; 22.6% in the Midwest (n = 2,060,940), 38.5% in the South (n = 3,527,814) and 18.7% in the West (n = 1,711,533). Mean age was 56 years with 57.7% being female. The Northeast had the highest risk-adjusted hospitalization rate (24.5%) followed by the South (18.6%, ORadj 0.58; 95% CI 0.52-0.65, p < 0.001), the Midwest (17.2%, ORadj 0.51; 95% CI 0.46-0.58, p < 0.001) and West (15.8%, ORadj 0.45; 95% CI 0.39-0.51, p < 0.001). Risk-adjusted rates of syncope hospitalizations significantly declined from 25.8% (95% CI 24.8%-26.7%) in 2006 to 11.7% (95% CI 11.0%-12.5%) in 2014 (P-trend < 0.001). The Northeast had the lowest risk-adjusted ED (Emergency Department) service charges per visit ($3320) followed by the Midwest ($4675, IRRadj 1.41; 95% CI 1.30-1.52, p < 0.001), the West ($4814, IRRadj 1.45; 95% CI 1.31-1.60, p < 0.001) and South ($4969, IRRadj 1.50; 95% CI 1.38-1.62, p < 0.001). Service charges increased from $3047/visit (95% CI $2912-$3182) in 2006 to $6267/visit (95% CI $5947-$6586) in 2014 (P-trend < 0.001). Conclusions: Significant regional variability in hospitalization rates and ED service charges exist among patients with syncope. Standardizing practices may be needed to reduce variability. (C) 2021 Elsevier Inc. All rights reserved.