Publications by Year: 2017

BACKGROUND AND AIMS: The full burden of the opioid epidemic on US hospitals has not been described. We aimed to estimate how heroin (HOD) and prescription opioid (POD) overdose-associated admissions, costs, outcomes and patient characteristics have changed from 2001 to 2012.

DESIGN: Retrospective cohort study of hospital admissions from the National Inpatient Sample (NIS).

SETTING: United States of America.

PARTICIPANTS: Hospital admissions in patients aged 18 years or older admitted with a diagnosis of HOD or POD. The NIS sample included 94 492 438 admissions from 2001 to 2012. The final unweighted study sample included 138 610 admissions (POD: 122 147 and HOD: 16 463).

MEASUREMENTS: Primary outcomes were rates of admissions per 100 000 people using US Census Bureau annual estimates. Other outcomes included in-patient mortality, hospital length-of-stay, cumulative and mean hospital costs and patient demographics. All analyses were weighted to provide national estimates.

FINDINGS: Between 2001 and 2012, an estimated 663 715 POD and HOD admissions occurred nation-wide. HOD admissions increased 0.11 per 100 000 people per year [95% confidence interval (CI) = 0.04, 0.17], while POD admissions increased 1.25 per 100 000 people per year (95% CI = 1.15, 1.34). Total in-patient costs increased by $4.1 million dollars per year (95% CI = 2.7, 5.5) for HOD admissions and by $46.0 million dollars per year (95% CI = 43.1, 48.9) for POD admissions, with an associated increase in hospitalization costs to more than $700 million annually. The adjusted odds of death in the POD group declined modestly per year [odds ratio (OR) = 0.98, 95% CI = 0.97, 0.99], with no difference in HOD mortality or length-of-stay. Patients with POD were older, more likely to be female and more likely to be white compared with HOD patients.

CONCLUSIONS: Rates and costs of heroin and prescription opioid overdose related admissions in the United States increased substantially from 2001 to 2012. The rapid and ongoing rise in both numbers of hospitalizations and their costs suggests that the burden of POD may threaten the infrastructure and finances of US hospitals.

RATIONALE: Opioid abuse is increasing, but its impact on critical care resources in the United States is unknown.

OBJECTIVES: We hypothesized that there would be a rising need for critical care among opioid-associated overdoses in the United States.

METHODS: We analyzed all adult admissions, using a retrospective cohort study from 162 hospitals in 44 states, discharged between January 1, 2009, and September 31, 2015 to describe the incidence of intensive care unit (ICU) admissions for opioid overdose during this time. Admissions were identified using the Clinical Database/Resource Manager of Vizient, the successor to the University Health System Consortium.

RESULTS: Our primary outcome was opioid-associated overdose admissions to the ICU. The outcome was defined on the basis of previously validated ICD-9 codes. Our secondary outcomes were in-hospital death and markers of ICU resources. The final cohort included 22,783,628 admissions; 4,145,068 required ICU care. There were 52.4 ICU admissions for overdose per 10,000 ICU admissions over the entire study (95% confidence interval [CI], 51.8-53.0 per 10,000 ICU admissions). During this time period, opioid overdose admissions requiring intensive care increased 34%, from 44 per 10,000 (95% CI, 43-46 per 10,000) to 59 per 10,000 ICU admissions (95% CI, 57-61 per 10,000; P < 0.0001). The mortality rate of patients with ICU admissions with overdoses averaged 7% (95% CI, 7.0-7.6%) but increased to 10% in 2015 (95% CI, 8.8-10.8%).

CONCLUSIONS: The number of deaths of ICU patients with opioid overdoses increased substantially in the 7 years of our study, reflecting increases in both the incidence and mortality of this condition. Our findings raise the need for a national approach to developing safe strategies to care for patients with overdose in the ICU, to providing coordinated resources in the hospital for patients and families, and to helping survivors maintain sobriety on discharge.

IMPORTANCE: A physician's prior experience caring for a patient may be associated with patient outcomes and care patterns during and after hospitalization.

OBJECTIVE: To examine differences in the use of health care resources and outcomes among hospitalized patients cared for by hospitalists, their own primary care physicians (PCPs), or other generalists.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective study analyzed admissions for the 20 most common medical diagnoses among elderly fee-for-service Medicare patients from January 1 through December 31, 2013. Patients had at least 1 previous encounter with an outpatient clinician within the 365 days before admission, and diagnoses were restricted to the 20 most common diagnosis related groups. Data were collected from Medicare Parts A and B claims data, and outcomes were analyzed from January 1, 2013, through January 31, 2014.

EXPOSURES: Physician types included hospitalists, PCPs (ie, the physicians who provided a plurality of ambulatory visits in the year preceding admission), or generalists (not the patients' PCPs).

MAIN OUTCOMES AND MEASURES: Number of in-hospital specialist consultations, length of stay, discharge site, all-cause 7- and 30-day readmission rates, and 30-day mortality.

RESULTS: A total of 560 651 admissions were analyzed (41.9% men and 59.1% women; mean [SD] age, 80 [8] years). Patients' physicians were hospitalists in 59.7% of admissions; PCPs, in 14.2%; and other generalists, in 26.1%. Primary care physicians used consultations 3% more (relative risk, 1.03; 95% CI, 1.02-1.05) and other generalists used consultations 6% more (relative risk, 1.06; 95% CI, 1.05-1.07) than hospitalists. Lengths of stay were 12% longer among patients cared for by PCPs (adjusted incidence rate ratio, 1.12; 95% CI, 1.11-1.13) and 6% longer among those cared for by other generalists (adjusted incidence rate ratio, 1.06; 95% CI, 1.05-1.07) compared with patients cared for by hospitalists. However, PCPs were more likely to discharge patients home (adjusted odds ratio [AOR], 1.14; 95% CI, 1.11-1.17), whereas other generalists were less likely to do so (AOR, 0.94; 95% CI, 0.92-0.96). Relative to hospitalists, patients cared for by PCPs had similar readmission rates at 7 days (AOR, 0.98; 95% CI, 0.96-1.01) and 30 days (AOR, 1.02; 95% CI, 0.99-1.04), whereas other generalists' readmission rates were greater than hospitalists' rates at 7 (AOR, 1.05; 95% CI, 1.02-1.07) and 30 (AOR, 1.04; 95% CI, 1.03-1.06) days. Patients cared for by PCPs had lower 30-day mortality than patients of hospitalists (AOR, 0.94; 95% CI, 0.91-0.97), whereas the mortality rate of patients of other generalists was higher (AOR, 1.09; 95% CI, 1.07-1.12).

CONCLUSIONS AND RELEVANCE: A PCP's prior experience with a patient may be associated with inpatient use of resources and patient outcomes. Patients cared for by their own PCP had slightly longer lengths of stay and were more likely to be discharged home but also were less likely to die within 30 days compared with those cared for by hospitalists or other generalists.