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OBJECTIVE Cancer and its treatment are known to be important risk factors for sepsis, contributing to an estimated 12% of U.S. sepsis admissions in the 1990s. However, cancer treatment has evolved markedly over the past 2 decades. We sought to examine how cancer-related sepsis differs from non-cancer-related sepsis. DESIGN Observational cohort. SETTING National Readmissions Database (2013-2014), containing all-payer claims for 49% of U.S. POPULATION PATIENTS A total of 1,104,363 sepsis hospitalizations. INTERVENTIONS We identified sepsis hospitalizations in the U.S. National Readmissions Database using explicit codes for severe sepsis, septic shock, or Dombrovskiy criteria (concomitant codes for infection and organ dysfunction). We classified hospitalizations as cancer-related versus non-cancer-related sepsis based on the presence of secondary diagnosis codes for malignancy. We compared characteristics (site of infection and organ dysfunction) and outcomes (in-hospital mortality and 30-d readmissions) of cancer-related versus non-cancer-related sepsis hospitalizations. We also completed subgroup analyses by age, cancer types, and specific cancer diagnoses. MEASUREMENTS AND MAIN RESULTS There were 27,481,517 hospitalizations in National Readmissions Database 2013-2014, of which 1,104,363 (4.0%) were for sepsis and 4,150,998 (15.1%) were cancer related. In-hospital mortality in cancer-related sepsis was 27.9% versus 19.5% in non-cancer-related sepsis. The median count of organ dysfunctions was indistinguishable, but the rate of specific organ dysfunctions differed by small amounts (e.g., hematologic dysfunction 20.1% in cancer-related sepsis vs 16.6% in non-cancer-related sepsis; p < 0.001). Cancer-related sepsis was associated with an adjusted absolute increase in in-hospital mortality ranging from 2.2% to 15.2% compared with non-cancer-related sepsis. The mortality difference was greatest in younger adults and waned with age. Patients (23.2%) discharged from cancer-related sepsis were rehospitalized within 30 days, compared with 20.1% in non-cancer-related sepsis (p < 0.001). CONCLUSIONS In this cohort of over 1 million U.S. sepsis hospitalizations, more than one in five were cancer related. The difference in mortality varies substantially across age spectrum and is greatest in younger adults. Readmissions were more common after cancer-related sepsis.

Introduction: We previously reported that age and race disparities exist in transfer for a higher level of care among acute ischemic stroke (AIS) patients. This study examined the association of transfer with in-hospital mortality stratified by age and race. Methods: In this cross-sectional analysis, we extracted AIS patient characteristics and transfer status from State Emergency Department Databases and State Inpatient Databases of 7 states between 1/1/2010-12/29/2010. We used stabilized inverse probability of treatment weights and fit generalized linear models with a flexible restricted cubic spline term for age, reporting risk differences (RDs) and risk ratios (RRs) with 95% confidence intervals (CIs). Because of potential unmeasured confounders, we reported E-values, which represent the minimum confounder-outcome and exposure-confounder RRs that could shift the associations to the null or the CI limits to include 1. Results: We identified 82,487 AIS discharges of whom 5.4% were transferred. After adjusting for age, race, gender, hospital type, minority-serving status, and Elixhauser comorbidities through weighting, transferred white patients, particularly age 2.0), but a weaker confounder could shift the CIs (RRs>1.5). The NIHSS has been reported to have E-values as high as 1.8. Conclusions: In our geographically diverse sample, we found that AIS transfer is associated with higher in-hospital mortality among white patients and younger black patients. Our data suggests that a strong unmeasured confounder could explain the association. Further work is needed to identify factors leading to higher mortality in transferred AIS patients.

The emergency department is an important venue for initial sepsis recognition and care. We sought to determine contemporary estimates of the epidemiology of U.S. emergency department visits for sepsis.Analysis of data from the National Hospital Ambulatory Medical Care Survey.U.S. emergency department visits, 2009-2011.Adult (age, ≥ 18 yr) emergency department sepsis patients. We defined serious infection as an emergency department diagnosis of a serious infection or a triage temperature greater than 38°C or less than 36°C. We defined three emergency department sepsis classifications: 1) original emergency department sepsis-serious infection plus emergency department diagnosis of organ dysfunction, endotracheal intubation, or systolic blood pressure less than or equal to 90 mm Hg or explicit sepsis emergency department diagnoses; 2) quick Sequential Organ Failure Assessment emergency department sepsis-serious infection plus presence of at least two "quick" Sequential Organ Failure Assessment criteria (Glasgow Coma Scale ≤ 14, respiratory rate ≥ 22 breaths/min, or systolic blood pressure ≤ 100 mm Hg); and 3) revised emergency department sepsis-original or quick Sequential Organ Failure Assessment emergency department sepsis.None.We used survey design and weighting variables to produce national estimates of annual adult emergency department visits using updated sepsis classifications. Over 2009-2011, there were 103,257,516 annual adult emergency department visits. The estimated number of emergency department sepsis visits were as follows: 1) original emergency department sepsis 665,319 (0.64%; 95% CI, 0.57-0.73); 2) quick Sequential Organ Failure Assessment emergency department sepsis 318,832 (0.31%; 95% CI, 0.26-0.37); and 3) revised emergency department sepsis 847,868 (0.82%; 95% CI, 0.74-0.91).Sepsis continues to present a major burden to U.S. emergency departments, affecting up to nearly 850,000 emergency department visits annually. Updated sepsis classifications may impact national estimates of emergency department sepsis epidemiology.

Introduction: We previously reported that “drip and ship” patients received at our tertiary center were younger and less often black when compared to those presenting directly. Given that disparities exist at many levels of acute ischemic stroke (AIS) care, the objective of this analysis was to determine if age and race disparities exist in inter-hospital transfer to a higher level of care (HLOC). Methods: In this cross-sectional analysis, we extracted patient characteristics and transfer status of AIS patients from the State Emergency Department Databases (SEDD) and Inpatient Databases (SID) of 5 states between 1/1/2010 and 12/29/2010. Hospital characteristics were determined using the American Hospital Association Database and The Joint Commission. We used Poisson regression with robust variance estimation adjusted for age, gender, payer type, Elixhauser comorbidities, and state to estimate prevalence ratios (PRs) and the proportion of whites and blacks, aged 18-64 or ≥65 years transferred by PSC status and hospital AIS volume. Results: We identified 58,321 AIS discharges (29% age 18-64 years) of whom 4.8% were transferred to a HLOC. Blacks were less likely to be transferred compared with whites (3.9% vs. 5.0%, PR 0.76; 95% CI 0.68-0.84). Among those age 18-64 years presenting to very low volume non-PSC hospitals (2 AIS discharges/month), blacks had a lower predicted percent transferred when compared with whites (16.2% vs 29.9%: 13.6% difference; 95% CI 6.6-20.6[Figure 1]). Differences by race were present for non-PSC hospitals with volumes as large as 8 AIS discharges/month (9.8% vs. 12.7%: 2.9% difference; 95% CI 0.9-4.9). Similar, although smaller, differences were observed in older patients (data on minority serving hospitals to be presented also). Conclusions: These findings suggest that age and race disparities exist in inter-hospital transfer for AIS. Specifically, black AIS patients aged

Objective:We sought to derive and internally validate a Sepsis Risk Score and a Severe Sepsis Risk Score predicting future sepsis and severe sepsis events among community-dwelling adults.Design:National population-based cohort.Setting:United States.Subjects:A total of 30,239 community-dwelling adult

In the United States, national efforts to reduce hospital readmissions have been enacted, including the application of substantial insurance reimbursement penalties for hospitals with elevated rates. Readmissions after severe sepsis remain understudied and could possibly signify lapses in care and missed opportunities for intervention. We sought to characterize 7- and 30-day readmission rates following hospital admission for severe sepsis as well as institutional variations in readmission.Retrospective analysis of 345,657 severe sepsis discharges from University HealthSystem Consortium hospitals in 2012.United States.We applied the commonly cited method described by Angus et al for identification of severe sepsis, including only discharges with sepsis present at admission.None.We identified unplanned, all-cause readmissions within 7 and 30 days of discharge using claims-based algorithms. Using mixed-effects logistic regression, we determined factors associated with 30-day readmission. We used risk-standardized readmission rates to assess institutional variations. Among 216,328 eligible severe sepsis discharges, there were 14,932 readmissions within 7 days (6.9%; 95% CI, 6.8-7.0) and 43,092 within 30 days (19.9%; 95% CI, 19.8-20.1). Among those readmitted within 30 days, 66.9% had an infection and 40.3% had severe sepsis at readmission. Patient severity, length of stay, and specific diagnoses were associated with increased odds of 30-day readmission. Observed institutional 7-day readmission rates ranged from 0% to 12.3%, 30-day rates from 3.6% to 29.1%, and 30-day risk-standardized readmission rates from 14.1% to 31.1%. Greater institutional volume, teaching status, trauma services, location in the Northeast, and lower ICU rates were associated with poor risk-standardized readmission rate performance.Severe sepsis readmission places a substantial burden on the healthcare system, with one in 15 and one in five severe sepsis discharges readmitted within 7 and 30 days, respectively. Hospitals and clinicians should be aware of this important sequela of severe sepsis.

Severe sepsis poses a major burden on the U.S. healthcare system. Previous epidemiologic studies have not differentiated community-acquired severe sepsis from healthcare-associated severe sepsis or hospital-acquired severe sepsis hospitalizations. We sought to compare and contrast community-acquired severe sepsis, healthcare-associated severe sepsis, and hospital-acquired severe sepsis hospitalizations in a national hospital sample.Retrospective analysis of severe sepsis discharges from University HealthSystem Consortium hospitals in 2012.United States.We used the criteria from Angus et al (discharge diagnoses for both a serious infection and organ dysfunction) to identify severe sepsis hospitalizations. We defined healthcare-associated severe sepsis as severe sepsis hospitalizations with an infection present at admission, where the patient was a nursing home resident, was on hemodialysis, or was readmitted within 30 days of a prior hospitalization. We defined community-acquired severe sepsis as all other severe sepsis patients with an infection present at admission. We defined hospital-acquired severe sepsis as severe sepsis patients where the documented infection was not present at admission.None.Prevalence of community-acquired severe sepsis, healthcare-associated severe sepsis, and hospital-acquired severe sepsis, adjusted hospital mortality, length of hospitalization, length of stay in an ICU, and hospital costs. Among 3,355,753 hospital discharges, there were 307,491 with severe sepsis, including 193,081 (62.8%) community-acquired severe sepsis, 79,581 (25.9%) healthcare-associated severe sepsis, and 34,829 (11.3%) hospital-acquired severe sepsis. Hospital-acquired severe sepsis and healthcare-associated severe sepsis exhibited higher in-hospital mortality than community-acquired severe sepsis (hospital acquired [19.2%] vs healthcare associated [12.8%] vs community acquired [8.6%]). Hospital-acquired severe sepsis had greater resource utilization than both healthcare-associated severe sepsis and community-acquired severe sepsis, with higher median length of hospital stay (hospital acquired [17 d] vs healthcare associated [7 d] vs community acquired [6 d]), median length of ICU stay (hospital acquired [8 d] vs healthcare associated [3 d] vs community acquired [3 d]), and median hospital costs (hospital acquired [$38,369] vs healthcare associated [$8,796] vs community acquired [$7,024]).In this series, severe sepsis hospitalizations included community-acquired severe sepsis (62.8%), healthcare-associated severe sepsis (25.9%), and hospital-acquired severe sepsis (11.3%) cases. Hospital-acquired severe sepsis was associated with both higher mortality and resource utilization than community-acquired severe sepsis and healthcare-associated severe sepsis.

The Centers for Disease Control and Prevention and U.S. Preventive Services Task Force have highlighted public screening as an essential strategy for increasing hepatitis C virus (HCV) detection in persons born between 1945 and 1965 (“baby boomers”). Because earlier HCV screening efforts have not targeted emergency department (ED) baby boomer patients, we describe early experience with integrated opt-out HCV antibody (Ab) screening of medically stable baby boomers presenting to an urban academic ED. We performed HCV Ab testing 24 hours per day and confirmed positive test results using polymerase chain reaction (PCR). The primary outcome was prevalence of unrecognized HCV infection. Among 2,325 unique HCV-unaware baby boomers, 289 (12.7%) opted out of HCV screening. We performed HCV Ab tests on 1,529 individuals, of which 170 (11.1%) were reactive. Among Ab reactive cases, follow-up PCR was performed on 150 (88.2%), of which 102 (68.0%) were confirmed RNA positive. HCV Ab reactivity was more likely in males compared to females (14.7% vs. 7.4%; P

Objective To characterize the relationship between stress and future risk of sepsis. We also evaluated the role of depression in this relationship. Methods We used population-based data on 30,183 participants in the Reasons for Geographic and Racial Differences in Stroke cohort, characterizing stress using the Perceived Stress Scale (PSS) and depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D). We identified incident sepsis events as hospitalizations for a serious infection with the presence of at least two systemic inflammatory response syndrome criteria. We assessed associations between PSS and incidence of sepsis for 1 and 10 years of follow-up, adjusting for demographics and chronic medical conditions and assessing the role of health behaviors and CES-D in these relationships. Results In 2003 to 2012, 1500 participants experienced an episode of sepsis. Mean PSS and CES-D scores were 3.2 (2.9) and 1.2 (2.1). PSS was associated with increased 1-year adjusted incidence of sepsis (hazard ratio [HR] = 1.21 per PSS standard deviation, 95% confidence interval = 1.06-1.38); multivariable adjustment for health behaviors and CES-D did not change this association (1.20, 1.03-1.39). PSS was also associated with increased 10-year adjusted incidence of sepsis (HR = 1.07 per PSS standard deviation; 95% confidence interval = 1.02-1.13). Multivariable adjustment showed that health behaviors did not affect this long-term association, whereas the addition of CES-D reduced the association between PSS and sepsis during 10-year follow-up (HR = 1.04, 0.98-1.11). Conclusions Increased stress was associated with higher 1-year adjusted incidence of sepsis, even after accounting for depressive symptoms. The association between stress and 10-year adjusted incidence of sepsis was also significant, but this association was reduced when adjusting for depressive symptoms. Reduction of stress may limit short-term sepsis risk.

Introduction: The risk of ischemic stroke doubles for each decade beyond the age of 55. While disparities, particularly racial disparities, have been described for many aspects of acute stroke care, these disparities have not been well characterized among older adults. The purpose of this analysis was to evaluate potential differences in IV-tPA utilization among acute ischemic stroke (AIS) patients aged ≥65 years. Methods: We used the Nationwide Inpatient Sample (NIS) to examine primary AIS diagnosis discharges (ICD-9 codes 433.x1, 434.x1 and 436) from US hospitals over 2006-2011, among those aged ≥ 65 years. Utilization of IV-tPA was identified using procedure code 99.10. Multivariate logistic regression was conducted to determine age and race associations with IV tPA utilization. Results: Over the 6 year study period, we identified 1.5 million ischemic stroke discharges, with 3.9% receiving IV-tPA. Compared to discharges who did not receive treatment, those receiving IV-tPA were less likely to be female and black. The odds of women receiving IV-tPA were 10% lower than men. After adjusting for demographics, insurance, and medical comorbidities, the odds of women receiving IV-tPA were still 5% lower (Table). When compared to non-black discharges, older blacks were at 25% lower odds of receiving IV-tPA. After adjusting for demographics, insurance and medical comorbidities, older blacks were at 22% lower odds of receiving IV-tPA (Table). Conclusions: Among older Americans, women and blacks have lower odds of being treated with IV-tPA, even after adjusting for age, insurance and comorbidities. A greater understanding of the reasons for these unexplained differences in the fastest growing proportion of our population is needed.

Background: Spontaneous intracerebral hemorrhage (sICH) is associated with substantial disability, accounting for considerable resource utilization among stroke survivors. Debate exists about the timing and utilization of tracheostomy (Trach) and percutaneous gastrostomy (PEG) tube placement in sICH patients. We hypothesized that sICH survivors with PEG and/or Trach would have higher odds of 30-day readmission. Methods: We analyzed the 2013 Nationwide Readmissions Database, a nationally representative sample of hospital discharges. Patients with a primary discharge diagnosis of sICH (ICD-9 code 431) were included in the analysis. Repeat, pediatric, same-day events, head trauma, AVM/fistula, and discharges occurring in December were excluded. Patients who received PEG and/or Trach were identified using published algorithms. We defined readmission as any admission within 30-days of index hospitalization discharge. Odds ratios for 30-day readmission comparing exposed versus unexposed were estimated with adjustment for demographics, risk factors, and concurrent illness. All analyses were performed using survey design variables. Results: Among the 32,715 sICH index hospitalizations, 3,480 (10.6%) received a PEG and 1806 (5.5%) received a Trach. Overall 4,320 (13.2%) were readmitted within 30 days (PEG 20.5%, trach 18.9%). In the fully adjusted models, sICH patients with PEG had higher odds of readmission (OR 1.43, 95% CI 1.14-1.80), while patients with trach did not (OR 0.77, 95% CI 0.54-1.11). Predictors of readmission among individuals with and without PEG and Trach will be presented. Conclusions: sICH patients who underwent PEG placement had higher odds of 30-day readmission while patients receiving Trach did not. This finding suggests that heightened post-discharge surveillance of individuals receiving PEG may be warranted.

Introduction: Readmission for acute ischemic stroke (AIS) is an important quality of care metric, and has been tied to reimbursement penalties. We aimed to describe nationwide readmission for AIS patients, and the potential impact of IV-tPA and Intra Arterial Treatment (IAT) on 30-day readmission. Methods: We analyzed the 2013 Nationwide Readmission Database, a nationally representative, weighted probability sample of ~ 36 million discharges from short-term hospitals. We used ICD-9 codes to identify patients with diagnosis of AIS (434.x1, 434.x1, 439), and patients receiving IV-tPA (99.1) or IAT (39.74). We excluded repeat, pediatric, and same-day events, and discharges in December. We defined readmissions as any admission within 30-days of index hospitalization discharge. Using published methods, we classified events as planned or unplanned, and identified readmissions attributable to potentially preventable ambulatory care-sensitive conditions. Logistic regression, using survey design variables, was performed to report nationally-weighted estimates of odds ratios (OR) and 95% CIs for factors associated with readmission. Results: A total of 319,317 index cases were identified with a primary diagnosis of AIS. Figure 1 illustrates the overall and therapy specific proportions for 30-day readmissions. Overall 12.1% (95% CI: 11.9 -12.3) of AIS patients were readmitted during 30-day post index hospitalization discharge. After adjustment, both IV-tPA and IAT were significantly associated with lower odds of 30-day readmission. For patients receiving either IV-tPA or undergoing IAT, the OR for 30-day readmission was 0.71 (CI: 0.66 - 0.77). Subgroup analyses for patients older than 65, and reasons for readmission will be presented. Conclusion: Recanalization therapy for AIS is associated with 23-34% lower odds of readmission. Analyses are limited by lack of survival data; however, thrombolysis has not shown to increase mortality in clinical trials.

This study sought to characterize variations in severe sepsis mortality between hospitals in the United States. Hospital discharge data (2012) were used from the University HealthSystem Consortium (UHC), a cooperative of US not-for-profit academic medical centers and affiliated hospitals. Discharge diagnosis codes were used to define severe sepsis as the presence of a serious infection with at least 1 organ dysfunction on hospital presentation. Expected mortality was determined from UHC risk adjustment mortality models. Among the 188 hospitals in the analysis, there were 256 509 patients with severe sepsis on admission. The median number of severe sepsis cases per hospital was 1202 (interquartile range [IQR] = 718-1940). Severe sepsis observed mortality (median = 8.6%; IQR = 6.8%-10.3%; range = 0.9%-18.2%) and observed-to-expected (O:E) mortality ratios (median = 0.91; IQR = 0.77-1.05; range = 0.16-1.95) varied across the hospitals. Variations in institutional severe sepsis observed mortality rates and O:E mortality ratios were observed in this national consortium of major medical centers.

Background and Objective: Transcranial Doppler (TCD) is endorsed by the American Heart Association/American Stroke Association, the American Academy of Neurology, and the Neurocritical Care Society for use in aneurysmal subarachnoid hemorrhage (aSAH) for surveillance of cerebral vasospasm (CV). However, data on utilization of TCD for CV detection and monitoring in aSAH are lacking. We estimated the proportion of patients with aSAH receiving TCD monitoring using the Nationwide Inpatient Sample (NIS). Methods: Data from 2002-2011 NIS were used to calculate the number of discharges with a primary diagnosis of aSAH per 100,000 discharges. Descriptive analysis of nationwide trends in TCD prevalence was performed. Teaching hospitals were examined separately for TCD utilization rates and this was done biennially to prevent small numbers. Results: Between 2002 and 2011, a total of 256,089 patients were discharged with a diagnosis of aSAH of which 3,850 underwent TCD monitoring. aSAH accounted for an average of 67.1 discharges per 100,000 annually (95% CI 61.3-72.8) from 2002-2011. Of these, only 1.5% (95% CI 0.4-2.6) underwent TCD examination. In teaching hospitals, aSAH accounted for an average of 108.5 discharges per 100,000 biennially (95% CI, 96.2-120.8), of which 2% (95% CI 1.0-4.0) underwent TCD examination. TCD utilization increased from Conclusion: TCD is underutilized nationally in the care of aSAH. While the prevalence of TCD is low in teaching hospitals, it is nearly nonexistent in non-teaching hospitals.

Background: Guidelines recommend acute ischemic stroke (AIS) patients be transported rapidly to the closest certified stroke center (SC). The impact of SC care on transfer patients who do not receive acute revascularization therapy is not well understood. We sought to compare patient characteristics, adverse events (AEs), and short term functional outcomes in patients directly presenting to and transferred into a comprehensive stroke center (CSC). Methods: We conducted a retrospective review of consecutive AIS patients transferred to our CSC from March 2014-April 2015. We excluded patients who received tPA or endovascular therapy. Demographic and clinical data were collected. We compared AEs (hemorrhagic transformation [HT], DVT, PE, urinary tract infection [UTI], pneumonia [PNA], bacteremia) and poor short term functional outcome, as defined by modified Rankin scale (mRS) score 3-6, among patients directly admitted to our CSC and patients transferred to our CSC. Results: Of 589 patients who did not receive revascularization therapy, 24.4% were transfers. Transfers were disproportionately white (76.4 vs 57.8%, p Conclusion: Despite having more severe strokes and higher frequency of adverse events, patients transferred into our CSC for a higher level of care did not have worse short term functional outcomes. This highlights the importance of specialized inpatient care provided in NICUs and stroke units by experienced multidisciplinary teams.

Background & Purpose: Recent studies have suggested a “smoker’s paradox,” referring to higher recanalization rates and better outcomes after IV thrombolytic therapy for ischemic stroke in smokers compared to nonsmokers. Our goal was to evaluate whether this paradox exists for both IV and endovascular therapies (ET) in our population. Methods: We retrospectively evaluated consecutive AIS patients (March 2014-April 2015) admitted to our comprehensive stroke center. Patients were stratified by treatment: IV tPA, ET, or neither. The primary endpoint was the modified Rankin scale (mRS) at discharge (“favorable outcome” score 0- 2) analyzed by logistic regression adjusted for demographic factors and admission NIHSS score. Successful reperfusion after ET was classified as Thrombolysis in Cerebral Infarction (TICI) scores of 2b or greater on immediate angiographic imaging. Results: Of 765 patients, 29 % were smokers (n= 222) including 63 % white (Table). Among smokers, 15% received tPA and 3% of patients received ET. Among nonsmokers 14% received tPA and 6% received ET. There was no difference in favorable outcome between smokers and nonsmokers in patients treated with tPA (60.6% vs. 52.6%; P= 0.43) or ET (26% vs. 40.0%; P= 0.325). There was no difference between smokers and nonsmokers in re-canalization after ET (70.6 % vs. 70.0%; P= 0.62). In patients without tPA or ET treatment, favorable outcome was more frequent in smokers compared to nonsmokers (66.5% vs. 47.8 %; P< 0.001). In a regression model adjusted for admission NIHSS, age, gender, and race, the prevalence of good outcome in smokers was 18% more than nonsmokers. (PR 1.177; 95% CI: 1.021 - 1.409). Conclusions: Our study did not support presence of the “Smoker’s Paradox” in AIS patients who receive IV or ET therapy. A rigorous adjustment for risk factors is likely to eliminate the paradoxical finding of more frequent favorable outcome in smokers who have not received tPA or ET.

Introduction: The 2015 AHA guidelines for ICH management state that initial care of ICH patients should take place in an “ICU or a dedicated stroke unit with physician and nursing neuroscience acute care expertise”. This approach entails transferring ICH patients from community hospitals to centers with stroke expertise. Hypothesis: We explored national trends in transfer of ICH patients to teaching hospitals, and evaluated the differences in demographic, co-morbidity, resource utilization factors, and outcomes for transferred patients (TP) vs. directly admitted patients (DAP). Methods: From the National Inpatient Sample data for years 2006 to 2011, we identified patients with primary diagnosis of ICH (ICD-9 431). We assessed linear trends in the proportion of patients transferred over time using logistic regression. We constructed multivariate logistic regression models to explore the association of transfer status with inpatient mortality after controlling for significant factors. All analyses were performed using survey design variables, allowing us to report nationally-weighted estimates. Results: Our analysis subpopulation comprised of 232,009 patients, and 48,097 (20.7%, 95% CI: 17.8 - 23.9) were TP. There was a statistically significant increase in transfer over the 6 year period. (Figure 1). TP were younger, and were more likely to be white and have private insurance. The proportions of TP with hypertension, diabetes, congestive heart failure, and renal failure were also significantly smaller (Table 1). TP had lower adjusted odds of inpatient mortality as compared to DAP (Table 2). Conclusion: There is an increasing trend of transferring ICH patients to higher level of care. Care of transferred patients at specialized centers is associated with greater resource utilization and lower inpatient mortality. Evidence on optimal selection of patients benefiting from transfer, and long term functional outcomes are needed for policy planning.

Objective: Wide variation exists in cardiac arrest survival. Historically cardiac arrest research has focused upon clinical pre-arrest and intra-arrest factors to explain this variation in outcomes. In-hospital post-arrest care is increasingly recognized as an important aspect of survival. We sought to identify hospital characteristics associated with improved cardiac arrest survival. Methods: We examined all participating hospitals in the University Hospital Consortium (UHC) clinical database with more than 25 adult cardiac arrests in 2012. Cases were identified using International Classification of Diseases, 9th Edition, code 427.5 (cardiac arrest) or 99.60 (CPR), excluding prisoners, pregnant patients, transfers, and hospice patients. We estimated hospital-specific risk-standardized survival rates (RSSRs) using hierarchical logistic regression, adjusting for individual risk of mortality. Institutions in the highest RSSR quartile were compared with those in the lowest three quartiles using Pearson chi-square tests of association. Results: UHC institutions admitted 3,686,296 patients in 2012, of which 33,700 patients experienced cardiac arrest. Overall survival was 42.3% (95% CI 41.8-42.9) with median RSSR of 42.7% (IQR 35.5-50.8). Hospitals in the highest quartile of RSSR had higher cardiac arrest volume (median 193 vs. 150, p-value 0.019), higher annual surgical operation volume (21,177 vs. 14,122, 0.007), cared for patients from catchment areas with higher household income ($60,753 vs. $56,424, 0.027), and were more likely to be a trauma (79% vs 59%, 0.024) or cardiac surgery center (91% vs 70%, 0.007). In addition, hospital size (477 vs 415 beds, 0.060) and teaching status (77% vs. 62%, 0.067) demonstrated a trend toward association with higher RSSR. Conclusion: Among hospitals in the UHC, those with higher cardiac arrest and surgical case volume, patient household income, and availability of trauma and cardiac surgery were associated with improved RSSR.

Introduction: Depression may attenuate immune response and increase the risk for infection. The association of depression with sepsis risk is unknown. Methods: We conducted a population-based longitudinal cohort study using the national 30,239 subject REasons for Geographic and Racial Differences in