Patel, Nilay

Introduction: The treatment options for high and extreme-risk patients with severe symptomatic aortic stenosis have changed significantly over the past decade because of advances in transcatheter aortic valve replacement (TAVR). However new permanent pacemaker implant (PPI) remains an impending concern after TAVR. Hypothesis: We sought to determine the frequency, predictors and outcomes of patients requiring PPI after TAVR. Methods: We queried the National Inpatient Sample (NIS) database using the ICD-9-CM procedure code of 35.05 for transfemoral/transaortic and 35.06 for transapical replacement of aortic valve .We identified TAVR procedures associated with new permanent pacemaker implants using appropriate validated ICD-9-CM codes. Using multivariate analysis we further identified predictors of PPM implants Results: An estimated 8828 TAVR procedures were performed in United States between 2011-2012. 773 (8.7%) TAVR procedures were associated with PPIs. PPI were higher in older (age>80 years), White race, diabetics, left bundle branch block (LBBB), right bundle branch block (RBBB), transfemoral approach. The inhospital mortality ( 5.2% vs.4.6% ) , mean length of stay ( 9.8 vs. 8.3 days ) disposition to short term nursing facility was higher (38.2% vs. 32.1%) and mean total costs (82217$ vs. 52283$) was higher in TAVR + PPI group . On multivariate analysis, Age in 5 year increment [Odds ratio (OR) 1.11; Confidence interval (CI) 1.05-1.17, p<0.001], diabetes [OR 1.26; CI 1.07-1.49, p<0.001], LBBB [OR 1.99; CI 1.55-2.56, p<0.001], RBBB [OR 5.36; CI 3.80-7.55, p<0.001] were independent predictors of PPI. Transfemoral approach was associated with more PPI implants [OR 1.41; CI 1.12 -1.78, p<0.001] Conclusion: Age, baseline conduction system disturbances, diabetes, transfemoral approach emerged as independent predictors of PPI after TAVR. This study provides useful tools to identify high-risk patients for PPI after TAVR.

Background: There is sparse comparative data on short-term readmissions following Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Methods: The study cohort was derived from the National Readmission Data (NRD) 2013, a subset of the Healthcare Cost and Utilization Project (HCUP) sponsored by AHRQ. TAVR and SAVR were identified using appropriate ICD-9-CM codes (TAVR - 35.05, 35.06 & SAVR - 35.21, 35.22) as either primary or secondary procedural codes. Variables which could affect treatment assignment, were adjusted with propensity score match analysis and Match (1:1) cohort was generated. Readmission causes were identified by ICD 9 code in primary diagnosis. Results: Our analysis included 3,886 TAVR and SAVR procedures each in the propensity matched cohorts. There was no significant difference in terms of readmission rates amongst patients who underwent TAVR vs. SAVR [21.41% vs. 21.07% (OR: 1.02, 95% CI: 0.92 - 1.14) p = 0.702]. Cardiac etiologies were more likely to be responsible for readmissions following SAVR (42.66% vs. 35.91%, p = 0.006). Atrial fibrillation (AF) was a much more common cause of readmission following SAVR (7.81% vs. 3.37%, p <0.001). Overall vascular (3.24% vs. 1.32%, p = 0.006) and bleeding complications (9% vs. 6.2%, p = 0.025) were more likely to result in readmission in patients undergoing TAVR. Cost of care of index admission and readmission was similar in both groups. Readmission mortality was higher amongst patient with TAVR vs. SAVR (6.49 vs. 3.91, p = 0.02). 50% of TAVR and SAVR readmission occur within 11 days post discharge. Conclusion: In our study from a large nationwide database, there was no significant difference in readmission rate, median readmission rate and resource utilization between TAVR and SAVR. Arrhythmias especially AF accounted for more SAVR readmission and Bleeding/vascular complications were more commonly responsible for readmissions following TAVR.

Introduction: Heart failure with preserved ejection fraction(HFpEF) is a syndromemwith limited treatment modalities. Our control over 30 day readmissions and readmission outcomes is limited. Methods: HCUP’s Nationwide Readmissions Database (NRD) from 2013-14 was used for HFpEF related hospitalizations using ICD-9- CM diagnostic code:428.3x in primary diagnosis field. 30-day readmissions were identified and classified into two groups: same-hospital readmissions and different-hospital readmissions. A comparative analysis was conducted focused on three metrics - mortality, length of stay (LOS) and cost of hospitalization. We used hierarchical two-level modeling and propensity score matching to adjust for confounders. Results: Of the 94,988 readmitted patients (age &gt;65 years: 79%, Females: 61.45%) - 76,665 (80.70%) to the same hospital and rest to different hospitals. After adjusting extensive list of confounders, same hospital readmission was associated with better outcomes including in hospital mortality (OR: 0.73, 95% CI: 0.66 - 0.80, p&lt;0.001), LOS (Days: -1.14, 95% CI: -1.31 - -0.97, p&lt;0.001), Cost of care ($: -4208, 95% CI: - 4681 - -3734, p&lt;0.001). For validation of our results, we ran propensity score matching, showed similar results - in hospital mortality (6.23% vs 8.07%), LOS (6.30 ± 0.08 vs 7.47 ± 0.095), Cost of care (14042.7 ± 215.7 vs 18685.4 ± 279.2). Post hoc high-risk subgroup analysis were conducted and showed similar results (Figure). Number needed to treat (for mortality) was 74 patients. Up to ~ 100 million dollars could have been saved over 2 years. Conclusions: Considering scale of problem and limited option to prevent worse outcomes, Simple interventions such as redirecting patient to same hospital as previous admission would be beneficial.

Background: There is lack of data regarding impact of atherectomy on the length of stay (LOS) and cost of hospitalization in lower extremity arterial revascularization. Methods: HCUP’s Nationwide Inpatient Sample (NIS) 2012 was queried using the ICD-9- CM code for peripheral vascular disease and procedural codes 39.90 (bare metal stent - BMS), 00.55 (drug eluting stent - DES), 17.56 (peripheral atherectomy) and 39.50 for angioplasty. Only procedures performed in patients ≥18 years of age were included. Hierarchical mixed effects linear regression models were generated to evaluate multivariate predictors of LOS and hospitalization costs. Results: A total of 13,206 (weighted: 66,030) lower extremity arterial revascularizations were identified (43.8% female & 65.5% white). Out of these, atherectomy was utilized in 23.2%. Atherectomy utilization was associated with significant reduction in LOS (4.96 ± 0.11 days vs. 5.78 ± 0.07 days, p <0.001) but higher hospitalization cost ($ 25196 ± 359 vs. $ 23408 ± 185, p < 0.001). Multivariate analysis showed similar results with decrease in LOS (-0.71 days, -1.00 - - 0.43; p < 0.001) but higher hospitalization cost (+1875 $, +811 - +2940; p = 0.001) with atherectomy, which was matched by propensity score analysis. Additionally, emergent/urgent & weekend admissions and Charlson score ≥2 were further associated with increased LOS and hospitalization costs. (Figure) Conclusion: Our study demonstrates that atherectomy utilization is associated with significant reduction in length of stay, which was counterbalanced by a slight increase in hospitalization costs following lower extremity arterial revascularization.

Introduction: Use of transcatheter endovascular stenting has been increasing in the treatment of Coarctation of Aorta (CoA). The present study was undertaken on adults with CoA undergoing stent placement from the period of 2000 to 2011 to analyze the relationship of hospital volume to the outcomes of stenting in adults with CoA. Methods: We queried Healthcare Cost and Utilization Project (HCUP)’s Nationwide Inpatient Sample (NIS) database from 2000 to 2011. Patients with CoA were identified using ICD-9-CM diagnosis code of 747.10. Patients≥18 years of age undergoing endovascular stenting were identified using ICD-9-CM procedure code of 39.90. Hospital volume was divided into two groups with ≥3 and <3 procedures annually. The outcomes studied were procedure-related complications, length of stay (LOS), and cost in relation to the hospital volume. Complications were coded using specific patient safety indicator codes released by HCUP. Length of stay (≤1 and >1 days) and cost (≤ $13,830 and > $13,830) were divided at median and included in regression analysis. Results: No in-hospital death was reported in either group. Hospitals with ≥3 procedures annually had significantly lower incidence of complications (9.50% vs. 23.01%) compared to the hospitals with <3 procedures annually (p=0.002). After multivariate regression analysis, compared to hospitals with <3 procedures annually, the hospitals with ≥3 procedures annually had odds ratio (OR) of 0.40 (95% CI: 0.19-0.82, p=0.013) for having any complications, OR of 0.67 (95% CI: 0.39-1.17, p=0.15) for having LOS>1 day, and OR of 0.72 (95% CI: 0.45-1.13, p=0.15) for having cost>$13,830. Conclusion: Stenting in adults for aortic coarctation is remarkably safe and the outcomes of the procedure have improved in centers with annual hospital volume of ≥3 procedures, and there is also decreasing trend of procedure-related complications, shorter hospital stay, and lower costs compared to centers with annual volume <3 procedures.

Introduction: Over the past decade, Transcatheter Aortic Valve Replacement (TAVR) has emerged as a therapeutic option for treating severe aortic stenosis in high-risk patients. Patients with liver cirrhosis are at high risk for operative morbidity and mortality when they undergo cardiac surgery. In the present study, in-hospital outcomes are compared in cirrhotic patients undergoing TAVR vs. Surgical Aortic Valve Replacement (SAVR). Methods: The study population was derived from the National Inpatient Sample (NIS) for the years 2011 and 2012 using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes 35.21 and 35.22 for SAVR, and 35.05 and 35.06 for TAVR. Patients<50 years of age and those with concomitantly other valvular procedures were excluded. ICD-9-CM diagnosis codes were used to identify patients with liver cirrhosis including those with other manifestations of cirrhosis such as portal hypertension and esophageal varices. Using propensity score matching, two matched cohorts were derived in which the outcomes were compared using chi-square test, fisher’s exact test, and student’s t-test. Results: There were 30 cirrhotic patients in the SAVR and TAVR group each after propensity score matching. Compared to the TAVR group, the patients in the SAVR group had higher mean cost of hospitalization ($79,263 vs. $63,913, p=0.12), mean post-procedural length of stay (14.3 days vs. 6.2 days, p<0.01), any complications rate (80.0% vs. 60.0%, p=0.09), rate of transfusion of blood or blood products (56.7% vs. 30.0%, p=0.037) and liver complications rate (20.0% vs. 10.0%, p=0.4). The in-hospital mortality rate was same in both the groups (6.7%). Conclusions: In high-risk cirrhotic patients, TAVR is a viable option for aortic valve replacement compared to SAVR.

Introduction: Heart Disease and Stroke Statistics_2014 Update suggests more than 424,000 people suffer out of hospital cardiac arrest (OHCA) in the United States. Hypothesis: We assessed seasonal variation in OHCA from a large national hospitalisation database in the past decade. Methods: The Nationwide Inpatient Sample database was used to estimate the annual number of hospitalisations with from 2000-2011. Identification of out of hospital cardiac arrest related hospitalisations was based on the designation of the International Classification of Diseases (9th Edition) Clinical Modification (ICD-9-CM) diagnosis code 427.5 (OHCA) as the principal discharge diagnosis. The frequency of hospitalisation for each month cumulative over 11 years was calculated and divided by number of days in that month to obtain the mean hospitalisations per day for each month. All calculations were carried out using the weighted estimates approximating nationwide population estimates. Results: An estimated 93,209 hospitalisations with primary diagnosis of OHCA occurred in the United States from the beginning of the calendar year 2000 to the end of the calendar year 2011. The number of hospitalisations per day in each month is shown in Figure 1.The number of hospitalisation was maximum in the winter months and minimum in summer months. Specifically, the mean number of hospitalisation each day (averaged over 11 years) was least in August (242). There was a rising trend from August to January. The average number of hospitalisation was highest in January (310); thereafter, the hospitalisation rate dropped to a nadir in August. There was however no seasonal pattern in inhospital mortality. Conclusions: We identified for the first time in United States an impressive pattern of seasonal variation in hospitalisations for OHCA. Further efforts must be made to identify triggers and methods to prevent OHCA and reduce its burden on health care system.

Objective: To identify possible racial and/or health insurance disparities with respect to ablation procedures for atrial fibrillation (AF). Method: Using the Nationwide Inpatient Sample (2000-2011), we identified adult patients (pts) admitted with principle diagnosis of AF by ICD 9 code 427.31 who had catheter ablation (ICD 9 code - 37.34). We stratified patients by race (White, Black, Hispanic, and other minority racial groups), insurance status, age, gender, type of hospital, and type of hospital admission. A hierarchical mixed effect multivariate model was created to identify independent predictors of AF ablation. Results: Among 4,547,144 patients hospitalized with AF during the study period, 201,447(4.43%) underwent ablation procedures. In absolute numbers, the majority of the ablations were performed in Whites (65.7%) and patients with Medicare (66.7%) or private insurance (24.7%). After adjusting for confounding factors, the proportions of Black pts (compare to White), and Medicare, Medicaid, and Uninsured pts (compare to private insurance), receiving ablation therapy were lower (see table). Odds of having ablation were lower in older and female patients and higher in teaching hospitals and after elective admissions (p<0.001 for all comparisions). Similar racial and insurance disparities were observed over the time course of the study. Conclusion: We identified lower rates of AF ablation among black pts even after correction of other factors such as insurance. Ablation rates were also lower among patients without private insurance. These trends persisted during the study period of 2000-2011.

Objective: To identify racial and/or health insurance disparities in the population undergoing ablation for paroxysmal supraventricular tachycardia(PSVT). Method: We identified adult patients (pts) admitted with principle diagnosis of PSVT by ICD 9 code 427.0 who had catheter ablation (ICD 9 code - 37.34), using the Nationwide Inpatient Sample (2000-2011). We stratified patients by race (White, Black, Hispanic, and other minority racial groups)and insurance status, and a hierarchical mixed effect multivariate model was created to identify independent predictors of PSVT ablation. Results: 64,564(20.2%) patients underwent ablation out of 319,579 patients admitted for PSVT during the period of 2000-2011. In absolute numbers, the majority of ablations were performed in Whites (58.7%) and patients with Medicare (56.3%) or private insurance (30.1%). After adjusting for confounding factors, the odds of having ablation were lower in Black pts (compare to White), and Medicare, Medicaid, and Uninsured pts (compare to private insurance) (see table). Other predictors of lower rate of ablations were: older age and female patients while odds of receiving ablation were higher for elective admissions and in teaching hospitals (p<0.001 for all comparisons). Conclusion: In a population of pts admitted for PSVT, those without private insurance and Black pts were less like to be treated with catheter ablation; and, this disparity persisted from 2000-2011. Since catheter ablation for PSVT is generally considered a curative procedure, future studies are needed to identify the factors that lead to these disparities of care.

Background: Contemporary outcome data regarding effects of atherectomy in lower extremity arterial revascularization is lacking. Methods: We queried HCUP’s Nationwide Inpatient Sample (NIS) for 2012 using the appropriate primary ICD 9-CM diagnostic code for peripheral vascular disease and procedural codes 39.90 (bare metal stent - BMS), 00.55 (drug eluting stent - DES), 17.56 (peripheral artherectomy) and 39.50 for angioplasty. Only procedures performed in patients >= 18 years were included. Hierarchical mixed effects logistic regression models were generated to evaluate multivariate predictors of outcomes. Results: In total 13,206 (weighted: 66,030) lower extremity arterial revascularization were analyzed (65.5% white, 56.2% Male & 97.4% angioplasty). Atherectomy utilization (23.2%) was associated with significant reduction in amputation (11.5% vs 13.4%), any complications (13.2% vs 16.3%) and in hospital morality (0.8% vs 1.4%) compared to no atherectomy group (p < 0.001). Multivariate analysis showed similar results with decrease amputation (OR, 95% CI; p - value) (0.83, 0.71 - 0.97, p = 0.02) and in hospital mortality/any complication (0.79, 0.69 - 0.90, p = 0.001) with atherectomy (similar results were observed with propensity score matching). “Atherectomy only” was utilized only in 2.3%. post-hoc analysis also shows better outcomes when atherectomy was used with either angioplasty or stenting (figure a & b). subgroup multivariate analysis shows significant reduction in amputation when atherectomy was utilized in chronic limb ischemia (0.74, 0.59 - 0.93, p = 0.01) and with angioplasty (0.72, 0.60 - 0.87, p = 0.001) and trend towards advantage while used along with stents but not reaching statistical significant. Conclusion: Lower extremity atherectomy utilization was associated with significant reduction in amputation and overall complication. We observed better outcomes when atherectomy was used in conjunction with angioplasty.