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The opioid epidemic is a major public health crisis in the U.S. Contemporary data on opioid use disorder (OUD) related hospitalizations are needed. Our objective was to assess whether OUD hospitalizations and associated mortality are increasing over time and examine the factors associated healthcare utilization and mortality. We examined the rates of OUD hospitalizations and associated mortality using the U.S. National Inpatient Sample (NIS) data from 1998-2016. Multivariable-adjusted logistic regression assessed the association of demographic, clinical and hospital characteristics with inpatient mortality and healthcare utilization (total hospital charges, discharge to a rehabilitation facility, length of hospital stay) during the index hospitalization for opioid use disorder. We calculated the odds ratio (OR) and 95% confidence intervals (CI). We estimated 781,767 OUD hospitalizations. The rate of OUD hospitalization and associated mortality (/100,000 overall NIS hospitalizations) increased from 59.8 and 1.2 in 1998-2000 to 190.7 and 5.9 in 2015-16, respectively. In the multivariable-adjusted analysis, the following factors were associated with worse outcomes; compared to age <34 years, older age was associated with higher risk of hospital charges above the median and length of stay >3 days, slightly higher risk of discharge to a rehabilitation facility. Higher Deyo-Charlson score was associated with higher hospital charges, length of hospital stay, and inpatient mortality. Women had lower odds of inpatient mortality than men and blacks had lower odds of mortality than whites. Rising OUD hospitalizations from 1998 to 2016 and increasing associated inpatient mortality are concerning. Certain groups are at higher risk of poor utilization outcomes and inpatient mortality. Resources and healthcare policies need to focus on the high-risk group to reduce mortality and associated utilization.

Objective To assess whether acute kidney injury (AKI) is associated with more complications and higher healthcare utilization in people undergoing primary total hip arthroplasty (THA). Methods Using a retrospective cohort study design, we performed multivariable-adjusted logistic regression of the 1998–2014 US National Inpatient Sample data to assess the association of AKI with complications (infection, transfusion, revision, and mortality) and healthcare utilization (total hospital charges, discharge to a rehabilitation facility, length of hospital stay) post-THA. We calculated the odds ratio (OR) and 95% confidence intervals (CI). Results Adjusted for age, gender, race, income, underlying diagnosis, medical comorbidity, and the insurance payer, AKI in people who underwent primary THA was associated with significantly higher OR (95% CI) of (1) implant infection, 2.34 (95% CI, 1.87, 2.93); (2) transfusion, 2.46 (95% CI, 2.37, 2.56); (3) revision, 2.54 (95% CI, 2.16, 2.98); (4) death, 8.52 (95% CI, 7.47, 9.73); (5) total hospital charges above the median, 2.29 (95% CI, 1.99, 2.65); (6) discharge to a rehabilitation facility, 2.11 (95% CI, 2.02, 2.20); and (7) hospital stay > 3 days, 4.34 (95% CI, 4.16, 4.53). Conclusion Quality improvement initiatives with optimization of the peri-operative care to reduce AKI and subsequently AKI-associated complications and healthcare utilization are needed. Mechanisms of AKI-associated post-THA complications need further examination.

Background Hyperuricemia and gout have been linked to chronic kidney disease (CKD) . Whether the increased risk of CKD in gout is due to shared risk factors such as hypertension, diabetes or heart disease, or due to gout itself is not known. Studies in older adults, who tend to have a high incidence of CKD, are limited. Our objective was to assess whether gout was associated with incident CKD in older adults. Methods Using the 5% random sample of Medicare claims, we assessed whether gout is associated with higher risk of incident (new) CKD in adults 65 years or older, using multivariable-adjusted Cox regression analyses, adjusting for demographics (age, gender, race), medical comorbidity and common medications. We calculated hazard ratios (HR) and 95% confidence interval (CI). Sensitivity analyses varied comorbidity variable (models 2, 3), or limited CKD to the most specific codes. Results Of the 1,699,613 eligible people, 168,065 developed incident CKD; 150,162 people without gout and 17,903 people with gout. Respective crude incidence rates were 15.6 vs. 78.1 per 1000 person-years. We found that gout was associated with a higher risk of incident CKD in multivariable-adjusted analyses, HR was 3.05 (95% CI, 2.99, 3.10), with minimal attenuation in sensitivity analyses, with HR 2.96 (95% CI, 2.91, 3.01) (model 2, categorical Charlson-Romano) and 2.59 (95% CI, 2.54, 2.63) (model 3, individual Charlson-Romano comorbidities plus hypertension, heart disease, obesity, coronary artery disease). Sensitivity analyses that limited the CKD diagnostic codes to more specific codes, confirmed findings from the main models with respective HRs of 3.10 (95% CI, 3.05, 3.15; Model 1), 3.03 (95% CI, 2.97, 3.08; Model 2) and 2.60 (95% CI, 2.56, 2.65; Model 3). Conclusion Gout was associated with a 3-fold higher risk of CKD, confirmed in multiple sensitivity analyses. Future studies should provide insights into underlying mechanisms that are responsible for an increased CKD risk in gout.

Background The purpose of this study was to assess the comparative effectiveness of allopurinol versus febuxostat for preventing incident dementia in older adults. Methods In a retrospective cohort study using Medicare claims data, we included patients newly treated with allopurinol or febuxostat (baseline period of 365 days without either medication). We used 5:1 propensity-matched Cox regression analyses to compare the hazard ratio (HR) of incident dementia with allopurinol versus febuxostat use and with allopurinol/febuxostat dose and duration. Results Crude rates of incident dementia per 100,000 person-days were lower with higher daily dose: allopurinol less than 200, 200 to 299, and at least 300 mg/day with 12, 9, and 8 and febuxostat 40 and 80 mg/day with 9 and 8, respectively. In propensity-matched analyses, compared with allopurinol use, febuxostat use was not significantly different, and the HR of incident dementia was 0.79 (95% confidence interval (CI) 0.61, 1.03). Compared with allopurinol less than 200 mg/day, higher allopurinol doses (200 to 299 and at least 300 mg/day) and the febuxostat 40 mg/day dose were each associated with lower HRs of dementia: 0.80 (95% CI 0.64, 0.98), 0.59 (95% CI 0.50, 0.71), and 0.64 (95% CI 0.47, 0.86), respectively. Compared with allopurinol use for 1 to 180 days, longer allopurinol or febuxostat use durations were not significantly associated with differences in HR of dementia (range of 0.76 to 1.14). Conclusions A dose-related reduction in the risk of dementia in older adults was noted with higher allopurinol dose and with febuxostat 40 mg daily dose. Future studies need to examine the mechanism of this benefit.

Objective To study incidence, time trends, and outcomes of serious infections in systemic sclerosis (SSc). Methods We used the 1998–2016 US National Inpatient Sample data. We examined the epidemiology, time trends, and outcomes of five serious infections (opportunistic infections (OI), skin and soft tissue infections (SSTI), urinary tract infection (UTI), pneumonia, and sepsis/bacteremia) in hospitalized people with SSc. We performed multivariable-adjusted logistic regression analyses to analyze independent association of factors with healthcare utilization (hospital charges, length of hospital stay, discharge to non-home setting) and in-hospital mortality. Results There were 49,904,955 hospitalizations with serious infections in people without SSc and 61,615 in those with SSc. During 1998–2016, the most common serious infections in SSc were pneumonia (45%), sepsis (32%), SSTI (19%), UTI (3%), and OI (3%). In 2013–2014, sepsis surpassed pneumonia as the most common serious infection; by 2015–2016, sepsis was 1.8 times more common than pneumonia. Over the study period, hospital charges increased, while length of hospital stay and in-hospital mortality decreased, overall and for each serious infection. Multivariable-adjusted analyses showed that sepsis, age ≥ 80 years, and Deyo-Charlson score ≥ 2 were associated with significantly higher odds of healthcare utilization and in-hospital mortality, and Medicare or Medicaid insurance payer, Northeast location, urban teaching or non-teaching hospital, and medium or large hospital bed size with significantly higher odds of healthcare utilization. Conclusions Outcomes in people with SSc hospitalized with serious infections have improved over time, except higher hospital charges. Identification of factors associated with higher healthcare utilization and in-hospital mortality allows for developing interventions to improve outcomes.

To assess whether gout is associated with incident age-related macular degeneration (AMD). We used the 5% Medicare claims data from 2006-12 for all beneficiaries who were enrolled in Medicare fee-for-service (Parts A, B) and not enrolled in a Medicare Advantage Plan, and resided in the U.S. People were censored at the occurrence of new diagnosis of AMD, death or the end of study (12/31/2012), whichever occurred first. We used multivariable-adjusted Cox regression analyses to assess the association of gout with incident AMD, adjusted for demographics, comorbidity, and use of medications for cardiovascular disease and gout. Hazard ratios and 95% confidence intervals were calculated. In this observational cohort study, of the 1,684,314 eligible people, 116,097 developed incident AMD (6.9%). Incidence rates of AMD per 1,000 person-years were 20.1 for people with gout and 11.7 for people without gout. In multivariable-adjusted analyses, a diagnosis of gout was significantly associated with a higher risk of incident AMD with a hazard ratio of 1.39 (95% CI, 1.35, 1.43). This association was confirmed in sensitivity analyses that substituted Charlson-Romano comorbidity index continuous score with either a categorical Charlson-Romano comorbidity index score or individual Charlson-Romano index comorbidities plus hypertension, hyperlipidemia and coronary artery disease. Other covariates significantly associated with higher hazards of incident AMD were older age, female gender, White race/ethnicity, and higher Charlson-Romano comorbidity index score. We noted a novel association of gout with AMD in the elderly. Future studies should investigate the pathways that mediate this association.

Background Conflicting data in the literature raise the question whether gout, independent of its treatment, increases the risk of dementia in the elderly. Our objective was to assess whether gout in older adults is associated with the risk of incident dementia. Methods We used the 5% Medicare claims data for this observational cohort study. We used multivariable-adjusted Cox proportional hazard models to assess the association of gout with a new diagnosis of dementia (incident dementia), adjusting for potential confounders/covariates including demographics (age, race, sex), comorbidities (Charlson-Romano comorbidity index), and medications commonly used for cardiac diseases (statins, beta-blockers, diuretics, and angiotensin converting enzyme (ACE)-inhibitors) and gout (allopurinol and febuxostat). Results In our cohort of 1.71 million Medicare beneficiaries, 111,656 had incident dementia. The crude incidence rates of dementia in people without and with gout were 10.9 and 17.9 per 1000 person-years, respectively. In multivariable-adjusted analyses, gout was independently associated with a significantly higher hazard ratio of incident dementia, with a HR of 1.15 (95% CI, 1.12, 1.18); sensitivity analyses confirmed the main findings. Compared to age 65 to < 75 years, age 75 to < 85 and ≥ 85 years were associated with 3.5 and 7.8-fold higher hazards of dementia; hazards were also higher for females, black race or people with higher medical comorbidity. Conclusion Gout was independently associated with a 15% higher risk of incident dementia in the elderly. Future studies need to understand the pathogenic pathways involved in this increased risk.

Background In the presence of limited available data, our objective was to assess the association of gout with the risk of incident Parkinson’s disease (PD) in adults 65 years or older. Methods We used the 5% random sample of Medicare claims data from 2006 to 2012 to examine the association of gout with incident PD. The multivariable Cox regression model adjusted for demographics, comorbidity, and common cardiovascular disease and gout medications. We calculated hazard ratios (HR) and 95% confidence interval (CI). Sensitivity analyses adjusted for comorbidity categorically, or individually and for additional cardiovascular comorbidities. Results In a cohort study, 1.72 million Medicare beneficiaries were eligible. The mean age was 75 years (standard deviation [SD], 7.6), 58% were female, 86% were White and 37% had Charlson-Romano comorbidity index score of ≥2. We found that 22,636 people developed incident PD, 1129 with gout and 21,507 without gout. The respective crude incidence rates of incident PD were 3.7 vs. 2.2 per 1000 person-years. We found that gout was associated with 1.14-times higher hazard ratio (95% CI, 1.07, 1.21) of PD in the main analysis; findings were confirmed in sensitivity analyses. We noted that the risk differed slightly by age; ages 65–75, 75–85 and > 85 had hazard ratios of incident PD with gout of 1.27 (95% CI, 1.16, 1.39), 1.07 (95% CI, 0.97, 1.16) and 0.97 (95% CI, 0.79, 1.20), respectively, but no gender or race differences were noted. Conclusions Gout was associated with a higher risk of incident PD in older adults, with the risk being significant in the age group 65–75 years. Future studies need to assess the mechanisms of this increased risk.

Background Current evidence suggests that gout is independently associated with a higher risk of myocardial infarction (MI), but data in older adults at the highest risk of MI are lacking. Our objective was to examine whether gout is associated with a higher risk of incident MI in older adults. Methods We assessed the 2006–2012 Medicare 5% claims data for the association of gout at baseline with the occurrence of a new (incident) MI during follow-up (no diagnosis of MI in the baseline period of at least 1 year), adjusting for patient demographics, medical comorbidity (Charlson–Romano index), and commonly used cardiovascular and gout medications, in a Cox proportional hazards model. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. Results In a cohort of 1,733,613 eligible people, 14,279 developed incident MI: 13,029 MIs in people without gout and 1250 MIs in those with gout, with crude incident rates of 1.3 vs 4.1 per 1000 person-years, respectively. In multivariable-adjusted analyses, gout was significantly associated with a higher hazard of incident MI, with HR of 2.08 (95% CI 1.95, 2.21). Risk was minimally attenuated in sensitivity analyses that replaced the continuous Charlson–Romano index score with a categorical score or individual comorbidities, or expanding to a more sensitive diagnostic algorithm for incident MI, or additionally adjusting for obesity. Conclusions Gout was independently associated with a higher risk of MI in the elderly, aged 65 years or older. The role of inflammatory and other pathways need to be explored as underlying mechanisms for this association.

Background To assess whether Sjogren’s Syndrome (SS) is associated with outcomes after total knee or hip arthroplasty (TKA/THA). Methods We used the 1998–2014 U.S. National Inpatient Sample data. We performed multivariable-adjusted logistic regression analyses to assess the association of SS with healthcare utilization (hospital charges, length of hospital stay, discharge to non-home setting), and in-hospital complications (implant infection, revision, transfusion, mortality), controlling for important covariates and confounders. In sensitivity analyses, we additionally adjusted the main models for hospital location/teaching status, bed size, and region . Results We examined 4,116,485 primary THAs and 8,127,282 primary TKAs performed from 1998 to 2014; 12,772 (0.2%) primary TKAs and 6222 (0.2%) primary THAs were done in people with SS. In multivariable-adjusted models, SS was associated with a statistically significant higher odds ratio (OR; 95% confidence interval (CI)) of discharge to a rehabilitation/inpatient facility post-THA, 1.13 (1.00, 1.28), but not post-TKA, 0.93 (0.86, 1.02). We noted no differences in the length of hospital stay or hospital charges. SS was associated with significantly higher adjusted odds of in-hospital transfusion post-THA, 1.37 (1.22, 1.55) and post-TKA, 1.21 (1.10, 1.34). No significant differences by SS diagnosis were seen in hospital stay, hospital charges implant infection, implant revision or mortality rates. Conclusions People with SS had higher transfusion rate post-TKA/THA, and higher rate of discharge to non-home setting post-THA. The lack of association of SS with post-arthroplasty complications should reassure patients, surgeons and policy-makers about the utility of TKA/THA in people with SS undergoing these procedures.