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The Inpatient Burden and Comorbidities of Pyoderma Gangrenosum in Adults in the United States

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The Inpatient Burden and Comorbidities of Pyoderma Gangrenosum in Adults in the United States Henry Ford Health System Henry Ford Health System Scholarly Commons Dermatology Articles Dermatology 7-3-2020 The inpatient burden and comorbidities of pyoderma gangrenosum in adults in the United States Shanthi Narla Henry Ford Health System, [email protected] Jonathan I. Silverberg Follow this and additional works at: https://scholarlycommons.henryford.com/dermatology_articles Recommended Citation Narla S, and Silverberg JI. The inpatient burden and comorbidities of pyoderma gangrenosum in adults in the United States. Arch Dermatol Res 2020. This Article is brought to you for free and open access by the Dermatology at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Dermatology Articles by an authorized administrator of Henry Ford Health System Scholarly Commons. Archives of Dermatological Research https://doi.org/10.1007/s00403-020-02098-7 ORIGINAL PAPER The inpatient burden and comorbidities of pyoderma gangrenosum in adults in the United States Shanthi Narla1 · Jonathan I. Silverberg2 Received: 24 April 2020 / Accepted: 17 June 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020 Abstract Hospital admission is often necessary for management of pyoderma gangrenosum (PG), including wound care and pain con- trol. No large-scale controlled studies examined the burden of hospitalization for PG. The objective of this study is to deter- mine the prevalence, predictors, outcomes, and costs of hospitalization for PG in United States adults. Data were analyzed from the 2002 to 2012 National Inpatient Sample, including a 20% representative sample of United States hospitalizations. The prevalence of hospitalization for PG increased between 2002 and 2012. Primary admission for PG was associated with age 40–59 years, female sex, black race/ethnicity, second-quartile household income, public or no insurance, and multiple chronic conditions. PG admissions were more likely at teaching and medium or large hospitals. Geometric-mean length and cost of hospitalization were higher in inpatients with vs. without a primary diagnosis of PG. The majority of inpatients with PG were classifed with minor (64.4%) or moderate (25.7%) likelihood of dying, but moderate (52.5%) and major (28.7%) loss of function. PG was associated with numerous other health disorders. The limitation of this study is the lack of data on PG treatment. This study demonstrated a substantial and increasing inpatient burden of PG in the United States, with considerable disability and mortality risk, multiple comorbid health disorders, and costs. Keywords Pyoderma gangrenosum · Inpatient · Comorbidities · Cost · Hospital · Mortality Abbreviations CCI Charlson comorbidity index ICD-9-CM International Classifcation of Disease 9th HCUP Healthcare cost and utilization project edition Clinical Modifcation AHRQ Agency for healthcare research and quality IBD Infammatory bowel disease LOS Length of stay PG Pyoderma gangrenosum APRDRG All Patient Refned Diagnosis-Related Group AIDS Acquired immunodefciency syndrome PUD Peptic ulcer disease DM Diabetes mellitus Introduction HS Hidradenitis suppurativa NIS Nationwide inpatient sample Pyoderma gangrenosum (PG) is a chronic, heterogeneous, CI Confdence interval infammatory skin disease characterized by aseptic neutro- philic infltration and systemic infammation. The most com- mon variant of PG is the ulcerative subtype, which typically Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s0040 3-020-02098 -7) contains presents as painful and pruritic erythematous lesions that supplementary material, which is available to authorized users. rapidly progress to blistered or necrotic ulcers most often on the lower extremities [1]. Wound care, anti-infammatory * Jonathan I. Silverberg treatments, and pain control are mainstays of treatment. Hos- [email protected] pitalization may be necessary for evaluation and manage- 1 Department of Dermatology, Henry Ford Hospital, Detroit, ment of rapidly progressive PG and less commonly chronic MI 48202, USA refractory disease. 2 Department of Dermatology, The George Washington The long-term outcome of PG remains poor with University School of Medicine and Health Sciences, Suite relapses occurring in up to 70% of cases and mortality rates 2B-430, 2150 Pennsylvania Avenue, Washington, DC 20037, as high as 30% [2]. A case series of 26 patients requiring USA Vol.:(0123456789)1 3 Archives of Dermatological Research hospitalization for PG was performed at an Australian ter- during hospitalization, including ventilation (overall, < 96 tiary teaching hospital. The median length of stay in the hos- or > 96 h), physical therapy, and diagnostic procedures on pital was 17 days (range 1–90 days), with 16 having multiple skin and subcutaneous tissue including skin biopsies, skin admissions. Investigations and treatments included c-reac- debridement, and skin grafting. Mortality risk and functional tive protein, wound cultures, dressings, topical treatments, severity were classifed according to the All Patient Refned and systemic immunosuppressive therapy [3]. A previous Diagnosis-Related Group (APRDRG) coded in NIS based on study of US inpatients compared the clinical characteristics software developed by the 3M Health Information Services of those hospitalized for PG with vs. without infammatory (2008). APRDRG incorporates severity of illness subclasses bowel disease (IBD); however, general associations and and is used to relate the type of patients treated to the costs trends in hospitalization for PG were not directly examined incurred by the hospital. Discharge status was assessed. [4]. A few large-scale studies examined the overall inpatient burden of PG, especially in the United States. Furthermore, Statistical analysis prior studies examined a limited set of PG comorbidities [5]. Despite the signifcant morbidity and risk of mortality, Data analyses were performed using SAS version 9.4 (SAS no large-scale controlled studies examined the multitude of Institute, Cary, NC). Weighted prevalence (95% CI) of hos- comorbidities of PG that have been reported in the literature, pitalization with a primary ICD-CM code of PG among including rarer disorders identifed in case reports and case inpatients was determined. Hospital cost for inpatient care series. This study sought to determine the prevalence, length was calculated based on the total charge of hospitalization of stay (LOS), and cost of care for hospitalization for PG and and the cost-to-charge ratio estimated by the Healthcare Cost medical comorbidities of PG in United States adults. and Utilization Project. Costs were adjusted for infation to the year 2014 according to the Consumer Price Index (US Bureau of Labor Statistics, 2015). Summary statistics were Methods generated for LOS, infation-adjusted cost of care, includ- ing sum, geometric mean, and 95% CI for hospitalizations The 2002–2012 National Inpatient Sample (NIS) was ana- with a primary or no diagnosis of PG. All statistical models lyzed. The NIS was developed as part of the Healthcare Cost employed SURVEY procedures, including discharge trend and Utilization Project (HCUP) sponsored by the Agency weights, sample strata accounting for hospital’s census for Healthcare Research and Quality (AHRQ). Each year region or division, ownership/control, location/teaching and of the NIS contains an approximately 20% stratifed repre- number of beds that were provided by NIS, and clustering by sentative sample of all US hospitalizations. All data were individual hospital. These models allow for representative de-identifed. No attempts were made to identify any indi- weighted estimates of frequency and prevalence of hospital viduals in the database. Patient consent was not obtained as discharges across the United States. the databases were received de-identifed. All parties were Survey logistic regression models were used to determine compliant to HCUP’s formal data use agreement. The study the associations of hospitalization for PG. The dependent was approved by the institutional review board at North- variable was hospitalization with vs. without a primary western University. diagnosis of PG. The independent variables included age, The databases were searched for a primary discharge sex, race/ethnicity, health insurance, number of chronic diagnosis of PG using the International Classifcation of Dis- conditions, hospital location, teaching status of hospital, eases, Ninth Revision, Clinical Modifcation (ICD-9-CM) admission month/season, hospital region, median house- code 686.01 (Supplemental Table 1). A previous study hold income national quartile for patient ZIP Code, and validated the use of the ICD-9-CM code 686.01 in hospi- hospital bed size. Chronic conditions were determined tal databases to identify PG [6]. The NIS defned primary using the HCUP chronic condition indicator for conditions diagnosis as the medical condition principally responsible lasting ≥ 12 months and meeting one or both of the follow- for the hospitalization of the patient and was assigned at ing: places limitations on self-care, independent living, and the time of hospital discharge. The control group included social interactions and/or results in the need for ongoing all hospitalizations without any PG and excluded normal intervention with medical products, services, and special pregnancy/delivery, yielding a representative cohort of US equipment. Crude odds ratios (ORs) and 95% CIs were esti- hospitalizations. mated. Multivariate regression
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