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      Hospitalizations for Valvular Heart Disease in Chronic Dialysis Patients in the United States

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          Background: Valvular heart disease has not been studied in a national population of end stage renal disease patients. Methods: 327,993 dialysis patients in the United States Renal Data System initiated from 1 January 1992 to 30 June 1997 were analyzed in a historical cohort study of patients hospitalized for valvular heart disease (ICD9 Code 424.x, excluding endocarditis, and 394.x-397.x). Results: 2,778 dialysis patients were hospitalized for VHD (incidence rate, 3.57 per 1,000 person years), and dialysis patients had an age-adjusted incidence ratio for valvular heart disease of 5.06 (95% confidence interval, 4.00–6.42) compared to the general population in 1996. In Cox regression analysis, time to hospitalization for valvular heart disease was associated with earlier year of first dialysis, increased age, congestive heart failure and use of erythropoietin prior to dialysis, while African-American race (AHR 0.62, 0.52–0.74) was associated with decreased risk of hospitalization for valvular heart disease. Patients hospitalized for valvular heart disease had increased mortality compared to all other dialysis patients (adjusted hazard ratio by Cox regression 1.35, 95% CI, 1.25–1.46). Conclusions: Dialysis patients were at increased risk for hospitalizations for valvular heart disease compared to the general population, which substantially decreased patient survival. The reasons for the decreased risk of African-Americans on chronic dialysis for this complication should be the subject of future trials.

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          Calcification of the Aortic Arch

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            Possible influence of the prospective payment system on the assignment of discharge diagnoses for coronary heart disease.

            The prospective payment system, under which diagnosis-related groups (DRGs) are used to reimburse hospitals for the care of Medicare patients, replaced the fee-for-service method of payment in Rhode Island in 1983 and in Massachusetts in 1985. Changes in financial incentives resulting from the use of the DRG system may have influenced the assignment of discharge diagnostic codes away from those with lower reimbursement toward codes with higher reimbursement. We collected data from the hospital records of patients 35 through 74 years of age who were discharged with codes 410 through 414 (representing various categories of coronary heart disease) of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The patients were discharged from seven hospitals in two New England communities (one in Rhode Island and one in Massachusetts) between 1980 and 1988. The rates of diagnosis of various forms of coronary heart disease were determined by studying ICD-9-CM hospital discharge codes (codes 410 and 411 for acute forms of coronary heart disease and codes 412, 413, and 414 for chronic forms) and by using a computerized diagnostic algorithm designed to detect definite myocardial infarction and fatal coronary heart disease. The rates of definite coronary events diagnosed by the algorithm and by the study of ICD-9-CM codes 410 through 414 were constant or increased slightly during the study period. However, the frequency of assignment of codes for the acute forms of coronary heart disease (which entail higher reimbursement) rose from 35.2 percent to 48.4 percent among discharged patients with cardiac disease after the institution of DRGs. The majority of this increase was associated with the code for unstable angina pectoris. The frequency of assignment of codes for the chronic forms of coronary heart disease (which entail lower reimbursement) decreased reciprocally, from 64.8 percent to 51.6 percent (P < 0.001). Our data are consistent with the hypothesis that the prospective reimbursement system has influenced the assignment of hospital discharge codes in a way that would increase payment to hospitals. However, the data do not permit us to distinguish whether hospitals began to assign more precise diagnoses with the advent of the DRG system, or whether they began to favor diagnoses of acute conditions solely for financial reasons.
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              Mortality after aortic valve replacement: results from a nationally representative database.

              Nationally representative estimates of in-hospital mortality after aortic valve replacement are needed to evaluate whether results from The Society of Thoracic Surgeons National Cardiac Surgery Database are applicable to other institutions in the United States performing these procedures. Data from the 1994 Nationwide Inpatient Sample were used to estimate the patient characteristics and in-hospital mortality rates associated with aortic valve replacements performed in nonfederal hospitals in the United States. Procedural and hospital characteristics were examined for possible associations with in-hospital mortality. An estimated 46,397 aortic valve replacements were performed. In-hospital mortality occurred in 4.3% of first-time isolated aortic valve replacements and 6.4% overall. The highest quartile of procedure-specific hospital volume, compared with the lowest quartile, was associated with lower in-hospital mortality (adjusted odds ratio, 0.58; 95% confidence interval, 0.42 to 0.81). The in-hospital mortality rates observed in this study are very similar to those reported from The Society of Thoracic Surgeons database. These data provide substantial evidence that results from The Society of Thoracic Surgeons database are representative of those achieved at other institutions. However, procedure-specific hospital volume must be considered in applying these results to individual institutions.

                Author and article information

                S. Karger AG
                September 2002
                14 August 2002
                : 92
                : 1
                : 43-50
                aNephrology Service, Walter Reed Army Medical Center, Washington, D.C.; bUniformed Services University of the Health Sciences, and cNational Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md., USA
                64476 Nephron 2002;92:43–50
                © 2002 S. Karger AG, Basel

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                Figures: 1, Tables: 3, References: 40, Pages: 8
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