Strained hospital capacity is associated with adverse patient outcomes. Anecdotal evidence suggests that during the COVID-19 pandemic in the US, some hospitals experienced capacity constraints while ...others in the same market had surplus capacity, a phenomenon known as "load imbalance." Our study evaluated the prevalence of intensive care unit load imbalance and the characteristics of hospitals most likely to be over capacity while other nearby hospitals were under capacity. Of the 290 hospital referral regions (HRRs) analyzed, 154 (53.1 percent) experienced load imbalance during the study period. HRRs experiencing the most imbalance had higher proportions of Black residents. Hospitals with the highest Medicaid patient shares and Black Medicare patient shares were significantly more likely to be over capacity, while other hospitals in their market were under capacity. Our findings highlight that hospital load imbalance was common during the COVID-19 pandemic. Policies to coordinate transfers may decrease strain during periods of high demand and ease the burden on hospitals that serve a higher proportion of patients from racial minority groups.
As health care markets in the United States have become increasingly consolidated, the role of market concentration on physician treatment behavior remains unclear. In cardiology, specifically, there ...has been evolving treatment of acute myocardial infarction complicated by cardiogenic shock (AMI-CS) with increasing use of mechanical circulatory support (MCS). However, there remains wide variation in it use. The role of market concentration in the utilization of MCS in AMI-CS is unknown. We examined the use of MCS in AMI-CS and its effect on outcomes between competitive and concentrated markets.
We used the National Inpatient Sample to query patients admitted with AMI-CS between 2003 and 2009. The primary study outcome was the use of mechanical circulatory support. The primary study exposure was market concentration, measured using the Herfindahl-Hirschman Index, which was used to classify markets as unconcentrated (competitive), moderately concentrated, and highly concentrated. Baseline characteristics, procedures, and outcomes were compared for patients in differently concentrated markets. Multivariable logistic regression was used to examine the association between HHI and use of MCS.
There were 32,406 hospitalizations for patients admitted with AMI-CS. Patients in unconcentrated markets were more likely to receive MCS than in highly concentrated markets (unconcentrated 46.8% 5087/10,873, moderately concentrated 44.9% 2933/6526, and high concentrated 44.5% 6676/15,007, p < 0.01). Multivariable regression showed that patients in more concentrated markets had decreased use of MCS in patients in later years of the study period (2009, OR 0.64, 95% CI 0.44-0.94, p = 0.02), with no effect in earlier years. There was no significant difference in in-hospital mortality.
Multivariable analysis did not show an association with market concentration and use of MCS in AMI-CS. However, subgroup analysis did show that competitive hospital markets were associated with more frequent use of MCS in AMI-CS as frequency of utilization increased over time. Further studies are needed to evaluate the effect of hospital market consolidation on the use of MCS and outcomes in AMI-CS.
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CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Background Re-hospitalization after discharge for acute decompensated heart failure is a common problem. Low-socioeconomic urban patients suffer high rates of re-hospitalization and often ...over-utilize the Emergency Department (ED) for their care. We hypothesized that early consultation with a cardiologist in the ED can reduce re-hospitalization and healthcare costs for low-socioeconomic urban patients with acute decompensated heart failure. Methods 392 patients treated at our center for acute decompensated heart failure received standardized education and follow-up. Patients who returned to the ED received early consultation with a cardiologist. 392 patients who received usual care served as controls. 30- and 90-day re-hospitalization, ED re-visits, heart failure symptoms, mortality, and healthcare costs were recorded. Results Despite guideline-based education and follow-up, the rate of ED re-visits was not different between the groups. However, the rate of re-hospitalization was significantly lower in patients receiving the intervention compared with controls (OR=0.592), driven by a reduction in the risk of readmission from the ED (0.56 vs. 0.79 respectively). Patients receiving the intervention accumulated 14% fewer re-hospitalized days than controls and 57% lower 30-day total healthcare cost. Despite the reduction in healthcare resource consumption, mortality was unchanged. After accounting for the total cost of intervention delivery, the healthcare cost savings was substantially greater than the cost of intervention delivery. Conclusions Early consultation with a cardiologist in the ED as an adjunct to guideline-based follow-up is associated with reduced re-hospitalization and healthcare cost for low-socioeconomic urban patients with acute decompensated heart failure.
Chronic thromboembolic pulmonary hypertension (CTEPH) is a sequela of a pulmonary embolus that occurs in approximately 1%−3% of patients. Pulmonary thromboendoarterectomy (PTE) can be a curative ...procedure, but balloon pulmonary angioplasty (BPA) has emerged as an option for poor surgical candidates. We used the National Inpatient Sample to query patients who underwent PTE or BPA between 2012 and 2019 with CTEPH. The primary outcome was a composite of in‐hospital mortality, myocardial infarction, stroke, tracheostomy, and prolonged mechanical ventilation. Outcomes were compared between low‐ and high‐volume centers, defined as 5 and 10 procedures per year for BPA and PTE, respectively. During our study period, 870 BPA and 2395 PTE were performed. There was a 328% relative increase in the number of PTE performed during the study period. Adverse events for BPA were rare. There was an increase in the primary composite outcome for low‐volume centers compared to high‐volume centers for PTE (24.4% vs. 12.1%, p = 0.003). Patients with hospitalizations for PTE in low‐volume centers were more likely to have prolonged mechanical ventilation (20.0%% vs. 7.2%, p < 0.001) and tracheostomy (7.8% vs. 2.6%, p = 0.017). In summary, PTE rates have been rising over the past 10 years, while BPA rates have remained stable. While adverse outcomes are rare for BPA, patients with hospitalizations at low‐volume centers for PTE were more likely to have adverse outcomes. For patients undergoing treatment of CTEPH with BPA or PTE, referral to high‐volume centers with multidisciplinary teams should be encouraged for optimal outcomes.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
There has been a dramatic increase in the use of intensive care units (ICUs) over the past 25 years. Greater use of validated measures of illness severity may better inform ICU admission decisions in ...patients with community-acquired pneumonia. This article examined predictors of ICU admission and hospitalization costs, including the pneumonia severity index (PSI) and CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥65 years) scores.
The study identified 422 patients hospitalized for community-acquired pneumonia, ascertaining patient characteristics by chart review and extraction of administrative data. Multivariate logistic regression was performed to quantify the association of the PSI, CURB-65 and comorbidities with ICU admission. The predictors of cost were estimated using a generalized linear model.
Compared to 194 general medicine patients, certain clinical and radiographic findings were more common among 228 ICU patients. Compared to PSI reference group I/II/III, ICU admission was strongly associated with risk class IV (odds ratio OR, 3.06; 95% confidence interval CI, 1.63-5.72) and V (OR, 4.84; CI, 2.44-9.62), and also CURB-65 ≥3 (OR, 2.90; CI, 1.51-5.56). The relative increase in mortality among PSI risk class V (compared to IV) patients was 2.68 times higher in general medicine, compared with the ICU. Among ICU admissions, risk class V was associated with an additional cost of $14,548 (95% CI, $4,232 to $24,864).
Illness severity and chronic pulmonary disease are strong predictors of ICU admission. More extensive use of the PSI may optimize site-of-care decisions, thereby minimizing mortality and unnecessary resource utilization.
Abstract
Background
Cardiac angiosarcoma is an exceptionally rare primary malignant tumour with an aggressive course and typically poor prognosis. Diagnosis is difficult, and patients often present ...with metastatic disease. We report the rare case of a patient with cardiac angiosarcoma who presents with constrictive physiology due to tumour encasement.
Case summary
A 65-year-old female with a past medical history of Hodgkin’s lymphoma and limited scleroderma presented with progressive dyspnoea on exertion. Multimodality imaging and haemodynamics with echocardiography, cardiac magnetic resonance imaging (MRI), and cardiac catheterization showed findings of constrictive physiology. Cardiac MRI showed areas of pericardial enhancement, so she was initially started on colchicine, prednisone, and mycophenolate mofetil to treat pericardial inflammation. However, her symptoms progressed, and she underwent pericardiectomy with cardiac surgery. Pericardium was noted to be thickened and a mass-like substance was densely adherent and potentially invading the heart itself and could not be dissected free. Surgical pathology showed features consistent with epithelioid angiosarcoma. Patient had rapid progression of her disease and was started on chemotherapy. Her course, however, was complicated by acute gastrointestinal bleeding, atrial fibrillation with rapid rates, and persistent volume overload. She elected for comfort measures and passed away shortly after her diagnosis.
Discussion
Our case shows an extremely rare diagnosis, cardiac angiosarcoma, presenting with typical findings of constrictive physiology. The case shows the typical features of constrictive physiology using multimodality imaging and haemodynamics and emphasizes the need to always think broadly in creating a differential diagnosis for constriction to ensure that rare diseases are considered.
Video Abstraacct
10.1093/ehjcr/ytad260_video1
Video Abstract
ytad260media1
6329795263112
The detection of spontaneous coronary artery dissection (SCAD) causing myocardial infarction is integral in pursuing the appropriate management. Our case posed a diagnostic challenge, with Takotsubo ...cardiomyopathy and coronary embolism among the potential differential diagnoses upon the initial presentation. Extensive propagation of spontaneous coronary artery dissection subsequently resulted in a significant challenge to management requiring surgical revascularization. (Level of Difficulty: Intermediate.)
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The detection of spontaneous coronary artery dissection (SCAD) causing myocardial infarction is integral in pursuing the appropriate management. Our case posed a diagnostic challenge…
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
A 67-year old women with a history of metastatic endometrial cancer, prior pulmonary embolism (PE) (on Xarelto) and mitral valve prolapse presented for 2-3 weeks of exertional dyspnea. Patient ...presented to oncology clinic with oxygen saturation (SpO2) in the mid-70% on room air requiring supplemental oxygen, and eventually high flow nasal cannula (HFNC). She was transferred to our cardiac intensive care unit for further management of her hypoxia. Physical exam was notable for decreasing SpO2 from supine (99%) to sitting (88%) to standing (79%). In this patient with metastatic cancer, differential diagnosis for hypoxia was broad including pneumonia, metastatic pulmonary disease, doxorubicin-induced cardiomyopathy, and PE. CT chest showed no signs of pulmonary edema, pneumonia, lung metastases, or PE. Transthoracic echocardiogram showed normal left and right ventricular function with moderate aortic regurgitation and mitral regurgitation. However, agitated saline injection showed right to left flow consistent with intraatrial shunt. Transesophageal echocardiogram confirmed large patent foramen ovale (PFO) with atrial septal aneurysm. Given physical examination findings, presence of PFO, and structural abnormalities of intraatrial septum, platypnea-orthodeoxia syndrome (POS) was considered. Right heart catheterization was completed to evaluate shunt physiology and showed unremarkable pressures (RA 1, RV 22/1, PCWP 3, PA 20/3, and LA 2). Venous oxygen saturations did not show any step-up suggesting left to right shunt. Exercise challenge did not result in any significant change in PA or PCWP pressures. Given persistent concern for POS without other clear diagnosis, patient underwent percutaneous closure of PFO with a 30mm Gore Cardioform septal occluder. Patient had resolution of her exertional hypoxia following procedure and was discharged home the next day. The case discusses 1) the importance of history of and physical exam in narrowing diagnosis, 2) utilization of multimodality imaging to evaluate intraatrial shunts, and 3) use of percutaneous methods for PFO closure.
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