Disparities in Demographics among

 

Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University
School of Medicine, Johns Hopkins Hospital. Baltimore, MD, USA.
2
Division of Gastroenterology
and Hepatology, Department of Medicine, State University of New York at Stony Brook,
Stony Brook University Medical Center. Stony Brook, NY, USA
ABSTRACT
Context Hospital admissions for pancreatitis are increasing. Factors involved in inpatient mortality have not been previously
assessed on a large-scale basis. Objective The aim was to study factors associated with pancreatitis-related death in hospitalized
patients. Setting Retrospective analysis of the 2004 U.S. Healthcare Cost and Utilization Project (HCUP) database was performed
using “pancreatitis” as admitting diagnosis and “mortality” as primary endpoint. Main outcome measures Age, race, gender,
income, length of stay, number of diagnoses, and number of procedures were identified as candidate risk factors associated with
death. Design Univariate and multivariate logistic regression analyses were performed to identify significant covariates. Results In
2004, total of 78,864 patients were admitted with pancreatitis; 2,129 (2.7%) patients died. Complete data were available for 57,068
patients. Age greater than 65 was 3 times more often associated with mortality (OR=2.92; P<0.001), while females were 19% less
likely to die (OR=0.81; P<0.001). African American patients were 18% more likely to die than whites (OR=1.18, P=0.025), and
increasing length of stay was associated with increasing mortality (more than 14 days compared with less than 3 days: OR=1.24;
P=0.004). Patients with more than 3 diagnoses and more than one hospital procedure were 17 times (OR=16.7; P<0.001) and 5 times
(OR=5.42; P<0.001) more likely to die, respectively. Compared to the lowest income quartile, patients in the 2nd and 3rd quartiles
were 19% (OR=0.81; P=0.004) and 17% (OR=0.83; P=0.016) less likely to die, respectively. Conclusion Age greater than 65 years,
male gender, multiple diagnoses, African American race and low income are strongly associated with inpatient mortality from
pancreatitis. Increased number of procedures and longer length of stay are also highly correlative with death.
INTRODUCTION
Acute pancreatitis is a relatively common clinical
condition hallmarked by unregulated trypsin activity
within the pancreatic acinar cell, leading to pancreatic
autodigestion and parenchymal inflammation [1]. The
most common risk factors for acute pancreatitis in
adults are gallstone disease and excess alcohol
ingestion [2, 3]. Chronic pancreatitis, on the other
hand, is a progressive fibro-inflammatory disease
characterized by irreversible loss of the pancreatic
parenchyma and subsequent functional insufficiency
[4]. Excess alcohol is the most common risk factor for
chronic pancreatitis in adults. Although the
pathogenesis differs for acute and chronic pancreatitis,
patients with chronic disease frequently present with
clinical episodes of acute pancreatitis [4, 5]. Both are
associated with significant morbidity and substantial
use of healthcare resources [6].
Each year in the United States more than 220,000
people are admitted to the hospital with pancreatitis,
and the number of admissions is steadily increasing [6,
7]. From 1988 to 2002, hospital admissions due to
acute pancreatitis rose from 101,000 to 210,000
annually, and the corresponding admission rate from
0.4 to 0.7 hospitalizations per 1,000 U.S. population
[8]. Approximately 20% of these patients have a severe
clinical course, and the overall mortality rate is
between 2% and 6% [1, 8]. Despite major advances in
intensive care units and other forms of supportive
treatment, mortality rates from pancreatitis have not
significantly declined [9].
The factors involved in inpatient mortality from
pancreatitis have not been previously assessed on a
Received August 22nd, 2008 - Accepted December 19th, 2008
Key words Demography; Mortality; Pancreatitis
Abbreviations HCUP: Healthcare Cost and Utilization Project;
NIS: National Inpatient Sample
Correspondence Patrick I Okolo, III
Johns Hopkins Hospital, Division of Gastroenterology, 1830 E.
Monument Street, Room 419, Baltimore, Maryland 21205, USA
Phone: +1-410.502.6761; Fax: +1-410.502.7010
E-mail: pokolo2@jhmi.edu
Document URL http://www.joplink.net/prev/200903/03.html

Page 2
JOP. J Pancreas (Online) 2009 Mar 9; 10(2):174-180.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 2 - March 2009. [ISSN 1590-8577]
175
large-scale basis. The aim of our study was to identify
those factors strongly associated with pancreatitis-
related death in a large sample of hospitalized patients.
METHODS
Study Design and Population
We performed a retrospective analysis of the 2004
Healthcare Cost and Utilization Project (HCUP)
database using its Nationwide Inpatient Sample
(HCUP-NIS)
to
facilitate
our
search
(http://www.ahrq.gov/data/hcup/). HCUP-NIS is the
largest inpatient care database in the United States. It
contains data from nearly 8 million hospital stays each
year, and maintains discharge diagnoses and
information from over 1,000 hospitals nationwide in 37
states. It is the only national hospital database
containing charge information on all patients,
regardless of payer; this includes patients covered by
Medicare and Medicaid (U.S. Department of Health
and Human Services; http://www.cms.hhs.gov/),
private insurance, and the uninsured. It encompasses
both urban and rural hospitals, as well as teaching and
non-teaching institutions. Data elements available
within the HCUP-NIS database include primary and
secondary diagnoses, primary and secondary
procedures, admission and discharge status, patient
demographics, expected payment source, total charges,
length of stay, and hospital characteristics.
In our study, the total burden of disease was captured
using the admission diagnosis search criterion of
“pancreatitis”. Mortality was ascertained by those
patients who registered inpatient hospital death during
2004.
Potential Predictors of Mortality
Patient-related and hospital course-related characteristics
were evaluated as potential predictors of mortality.
Patient-related factors included age, race, gender,
socioeconomic status, and the number of additional
comorbid conditions or diagnoses. Age was
categorized by using 65 years as cut-off value. Race
was divided into six groups: Caucasian, African
American, Hispanic, Asian or Pacific Islander, Native
American, and others. Socioeconomic status was
measured according to household income quartiles, and
the number of additional diagnoses was categorized as
less than, or equal to, 3 and more than 3 comorbid
conditions.
Hospital course-related factors included length of stay
and the number of inpatient hospital procedures.
Length of stay was divided into four groups: less than 3
days, 3-7 days, 8-14 days, and more than 14 days. The
number of inpatient procedures was categorized as one
procedure or 2 or more procedures.
STATISTICS
Data are reported as mean±SD and frequencies.
Statistical analyses were performed using Stata 9.0
(Stata Corp, College Station, TX, USA). The
hierarchical log-linear models were used to test the
distribution of race and hospital size. Univariate
logistic regression analysis was performed keeping
inpatient mortality as the main study outcome; odds
ratios (ORs) and 95% confidence intervals (95% CIs)
were computed. The simple contrast was applied to
non-dichotomic factors. In addition, we used multiple
logistic regression analysis in order to identify factors
that were independently associated with mortality.
Variables for the final logistic regression model were
selected by using a stepwise procedure, and the most
parsimonious predictive model was chosen using the
Akaike Information Criterion (AIC).
A receiver-operator-characteristic (ROC) curve was
assembled and the area under the curve (AUC) was
analyzed to evaluate thresholds for patients with and
without inpatient mortality to distinguish positives
from negatives. For each decision threshold, the test
sensitivity was derived from patients who had
deceased, and the test specificity from patients who had
notSensitivities and specificities were plotted as
functions of each other, with the upper left-hand corner
representing perfect discrimination.
RESULTS
In the year 2004, there were 78,864 patients admitted
to U.S. hospitals with a primary diagnosis of
pancreatitis and captured by the HCUP-NIS database.
Varying degrees of data were available in each of the
categories analyzed. Total of 57,068 patients had
complete data available. Information from at least
57,068 patients was used during data analysis for each
variable.
Table 1 highlights the characteristics of the hospitals
that were used in our analysis. Four separate regions
from within the United States were represented. The
South region of the country registered the highest
number of hospital admissions due to pancreatitis
(33,728; 42.8%). Most patients were admitted to
hospitals located in urban settings (67,109; 85.1%), and
the majority were non-teaching institutions (49,867;
63.2%). Nearly 60% of patients received their care at a
large-sized hospital (45,711; 58.0%); keeping in mind
that hospital bed size was dependent upon hospital
Table 1. Hospital characteristics in 78,864 admissions due to
pancreatitis.
Hospital characteristics
Number of admissions
U.S. region
- Northeast
- Midwest
- South
- West
12,896 (16.4%)
17,161 (21.8%)
33,728 (42.8%)
15,079 (19.1%)
Hospital location
- Urban
- Rural
67,109 (85.1%)
11,755 (14.9%)
Type of institution
- Teaching
- Non-teaching
28,997 (36.8%)
49,867 (63.2%)
Hospital bed size
- Large
- Medium
- Small
45,711 (58.0%)
22,169 (28.1%)
10,984 (13.9%)

Page 3
JOP. J Pancreas (Online) 2009 Mar 9; 10(2):174-180.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 2 - March 2009. [ISSN 1590-8577]
176
location according to the HCUP-NIS database (the
cutoff for a “large” hospital in a Western rural
community was 45 beds, as opposed to 425 beds for a
Northeastern urban institution).
According to bed size, there were 13.9% admissions in
small volume hospitals overall associated with a 2.3%
mortality rate for pancreatitis (n=255). There were
28.1% admissions in medium-sized hospitals
associated with a 2.4% mortality rate (n=536;
OR=1.04, 95% CI: 0.90-1.21), and 58.0% admissions
in large volume hospitals associated with a 2.9%
mortality rate (n=1,310; OR=1.24; 95% CI: 1.08-1.42).
Caucasian and Hispanic patients were more prevalent
in small hospitals (P<0.001), while most African
American patients were likely to present to large
volume hospitals (P<0.001). Therefore, a significant
higher frequencies of Asian or Pacific Islanders
(P=0.015), Native Americans (P<0.001) and other
races (P<0.001) were admitted in medium sized
hospitals than in small or high sized ones (Table 2).
Table 3 demonstrates the inpatient demographics for all
available data within the HCUP-NIS database. In
78,864 patients hospitalized with pancreatitis, 2,129
(2.7%) died prior to discharge. Mean age at the time of
admission was 53.2±19.0 years, half were female
(39,765 out of 78,662; 50.6%), and the majority of
patients were Caucasian (36,728 out of 58,455; 62.8%).
Mean number of comorbid conditions or additional
diagnoses was 7.1±3.6.
In terms of hospital course, mean length of stay was
6.7±8.9 days. Average number of inpatient procedures
was 1.5±2.1, and total hospital charges were
$30,777±55,402. Ninety-two percent of hospital
admissions (71,908 out of 78,542) were considered
non-elective, or arrival through the emergency room
(Table 3).
Results of the univariate logistic regression analysis are
shown in Table 4, summarizing the odds ratios (ORs)
with respective P-values for the seven separate groups
of covariate factors most strongly associated with
pancreatitis-related mortality. Among the patient-
related factors, age greater than 65 years old (OR=3.60,
95% CI: 3.30-3.93; P<0.001) and more than 3
comorbid conditions (OR=21.69, 95% CI: 13.80-34.09;
P<0.001) were strongly associated with inpatient
mortality. Compared to Caucasians, African American
patients (OR=1.02, 95% CI: 0.90-1.16) and Asian
patients (OR=1.58, 95% CI: 1.20-2.09) were more
likely to die, but this was only statistically significant
for Asian patients (P=0.001). Female gender was less
associated with mortality (OR=0.87, 95% CI: 0.80-
0.95; P=0.002), and compared to patients in the lowest
income quartile, those in the 2nd quartile were less
likely to die (OR=0.89, 95% CI: 0.79-1.00; P=0.051).
Among the hospital course-related factors, univariate
analysis showed a significant association with inpatient
mortality in patients with more than one procedure
(OR=6.33; 95% CI: 5.72-7.01; P<0.001; Table 4).
Furthermore, increasing length of stay was strongly
associated with increasing mortality (length of stay 8-
14 days, OR=1.55, 95% CI: 1.37-1.75, P<0.001; length
of stay more than 14 days, OR=4.77, 95% CI: 4.27-
5.33, P<0.001) while the lowest mortality was found in
patients with 3-7 days of length of stay (OR=0.59; 95%
CI: 0.52-0.67).
Table 2. Distribution of admissions according to race and hospital bed size.
Race
Hospital bed size
Total
Large
Medium
Small
Caucasian
21,271 (62.7%)
P<0.001
10,214 (61.0%)
P<0.001
5,243 (67.3%)
P<0.001
36,728 (62.8%)
African American
7,065 (20.8%)
P<0.001
2,411 (14.4%)
P<0.001
1,271 (16.3%)
P=0.842
10,747 (18.4%)
Hispanic
4,194 (12.4%)
P<0.001
2,756 (11.0%)
P=0.121
866 (11.1%)
P<0.001
7,816 (13.4%)
Asian or Pacific Islander
662 (2.0%)
P=0.460
412 (2.8%)
P=0.015
179 (2.3%)
P=0.166
1,253 (2.1%)
Native American
147 (0.4%)
P<0.001
214 (8.2%)
P<0.001
69 (0.9%)
P=0.039
430 (0.7%)
Other
594 (1.8%)
P<0.001
730 (14.9%)
P<0.001
157 (2.0%)
P=0.001
1,481 (2.5%)
Total
33,933
16,737
7,785
58,455
P values were evaluated by means of the hierarchical log-linear models
Table 3. Inpatient demographics within HCUP-NIS database
(mean±SD, or frequencies).
Age (years; mean±SD)
53.2±19.0
Died during hospitalization
2,129 (2.7%)
Gender (n=78,662)
- Male
- Female
38,897 (49.4%)
39,765 (50.6%)
Race (n=58,455)
- Caucasian
- African American
- Hispanic
- Asian or Pacific Islander
- Native American
- Other
36,728 (62.8%)
10,747 (18.4%)
7,816 (13.4%)
1,253 (2.1%)
430 (0.7%)
1,481 (2.5%)
Number of diagnoses
7.1±3.6
Length of stay (days)
6.7±8.9
Number of procedures
1.5±2.1
Total hospital charges (U.S. $)
30,777±55,402
Type of admission (n=78,542)
- Elective
- Non-elective
6,634 (8.4%)
71,908 (91.6%)

Page 4
JOP. J Pancreas (Online) 2009 Mar 9; 10(2):174-180.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 2 - March 2009. [ISSN 1590-8577]
177
The two rightmost columns of Table 4 highlight the
results of the multivariate logistic regression analysis
for the same seven groups of covariate factors. Again,
there were significant correlations with pancreatitis-
related mortality in all seven categories. Age greater
than 65 years old (OR=2.92, 95% CI: 2.62-3.24;
P<0.001) and more than 3 comorbid conditions
(OR=16.74, 95% CI: 8.95-31.29; P<0.001) were strong
patient-related covariates. In terms of race, only
African American race was significantly associated
with mortality (OR=1.18, 95% CI: 1.02-1.36;
P=0.025). Furthermore, females had a likely lower
mortality than males (OR=0.81, 95% CI: 0.73-0.90;
P<0.001); and compared to patients in the lowest
income quartile, those in the 2nd and 3rd quartiles had
also a likely lower probability to die (OR=0.81, 95%
CI: 0.70-0.93; P=0.004 and OR=0.83, 95% CI: 0.72-
0.97; P=0.016, respectively). Those in the 4th quartile
of income were 13% less likely to die, but this did not
reach statistical significance (OR=0.87, 95% CI: 0.75-
1.01; P=0.060).
For the hospital course-related factors, multivariate
analysis showed a significant association with inpatient
mortality in patients with more than one procedure;
OR=5.42, 95% CI: 4.73-6.21, P<0.001 (Table 4).
Again, increasing length of stay was strongly
associated with increasing pancreatitis-related
mortality (length of stay greater than 14 days vs. 1-2
days: OR=1.24, 95% CI: 1.07-1.43, P=0.004) while
patients with length of stay 3-7 days (OR=0.31, 95%
CI: 0.27-0.37; P<0.001) and those with length of stay
8-14 days (OR=0.54, 95% CI: 0.46-0.63, P<0.001;)
had significantly lower mortality than patients with 1-2
days of stay.
Finally, all seven covariate factors were used to
generate the final multivariate logistic regression
model and a score of the probability to death was
computed for each patient by assigning 0 for factors in
the reference category or the linear combination of the
anti-log values of the ORs for factors different from the
reference category. The ROC curve assembled by
using this score yielded an AUC equal to 0.828 (95%
CI: 0.820-0.837), suggesting high predictive value
when estimating the likelihood of inpatient mortality
(Figure 1).
DISCUSSION
Acute pancreatitis is a common disease that is
primarily characterized by unregulated trypsin activity
and pancreatic autodigestion with parenchymal
inflammation [1]. It is associated with significant
morbidity, and it may easily progress to a systemic
inflammatory response syndrome with or without
multi-organ dysfunction [10, 11, 12, 13, 14]. The most
Table 4. Results of the univariate and multivariate logistic analysis performed keeping inpatient mortality as the main study outcome.
Factors
Mortality
Univariate analysis
Multivariate analysis
OR (95% CI)
P value
OR (95% CI)
P value
Patient-related factors
Age
- 0-65 years
- More than 65 years
893/56,620 (1.6%)
1,208/22,131 (5.5%)
Reference
3.60 (3.30-3.93)
-
<0.001
Reference
2.92 (2.62-3.24)
-
<0.001
Diagnoses
- 0-3 comorbidities
- More than 3
19/12,694 (0.1%)
2,082/66,104 (3.1%)
Reference
21.69 (13.80-34.09)
-
<0.001
Reference
16.74 (8.95-31.29)
-
<0.001
Race
- Caucasians
- African American
- Hispanic
- Asian or Pacific Islander
- Native American
- Other
1,054/36,712 (2.9%)
314/10,742 (2.9%)
162/7,816 (2.1%)
56/1,252 (4.5%)
5/430 (1.2%)
37/1,481 (2.5%)
Reference
1.02 (0.90-1.16)
0.72 (0.61-0.85)
1.58 (1.20-2.09)
0.40 (0.16-0.96)
0.87 (0.62-1.21)
<0.001 a
-
0.776
<0.001
0.001
0.041
0.399
Reference
1.18 (1.02-1.36)
0.85 (0.71-1.01)
1.21 (0.90-1.62)
0.61 (0.25-1.50)
0.98 (0.69-1.38)
0.001 a
-
0.025
0.070
0.203
0.285
0.899
Gender
- Male
- Female
1,109/38,879 (2.9%)
992/39,755 (2.5%)
Reference
0.87 (0.80-0.95)
-
0.002
Reference
0.81 (0.73-0.90)
-
<0.001
Income
- 1st quartile (0-35,999 U.S. $)
- 2nd quartile (36,000-44,999 U.S. $)
- 3rd quartile (45,000-58,999 U.S. $)
- 4th quartile (59,000 U.S. $, or more)
689/25,250 (2.7%)
496/20,359 (2.4%)
450/16,471 (2.7%)
416/14,859 (2.8%)
Reference
0.89 (0.79-1.00)
1.00 (0.89-1.13)
1.03 (0.91-1.16)
0.121 a
-
0.051
0.984
0.675
Reference
0.81 (0.70-0.93)
0.83 (0.72-0.97)
0.87 (0.75-1.01)
0.010 a
-
0.004
0.016
0.060
Hospital-related factors
Procedures
- One
- More than one
494/51,151 (1.0%)
1,607/27,647 (5.8%)
Reference
6.33 (5.72-7.01)
-
<0.001
Reference
5.42 (4.73-6.21)
-
<0.001
Length of stay
- 1-2 days
- 3-7 days
- 8-14 days
- More than 14 days
657/30,370 (2.2%)
373/29,127 (1.3%)
409/12,359 (3.3%)
662/6,942 (9.5%)
Reference
0.59 (0.52-0.67)
1.55 (1.37-1.75)
4.77 (4.27-5.33)
<0.001 a
-
<0.001
<0.001
<0.001
Reference
0.31 (0.27-0.37)
0.54 (0.46-0.63)
1.24 (1.07-1.43)
<0.001 a
-
<0.001
<0.001
0.004
OR: odds ratio; 95% CI: 95% confidence interval
Overall P value of the non-dichotomous factors

Page 5
JOP. J Pancreas (Online) 2009 Mar 9; 10(2):174-180.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 2 - March 2009. [ISSN 1590-8577]
178
common risk factors for acute pancreatitis in adults are
gallstone disease and excess alcohol ingestion [2, 3].
Other causes include medications, trauma, obstruction
of the pancreatic duct (e.g., tumor), and certain
metabolic derangements such as hypertriglyceridemia
[1].
Chronic pancreatitis is a progressive fibro-inflam-
matory disease characterized by irreversible loss of the
pancreatic parenchyma with subsequent functional
insufficiency [4]. Excess alcohol is the most significant
risk factor in adult patients, while genetic and
anatomical defects predominate in children [5].
Morbidity associated with chronic pancreatitis includes
chronic pain, intestinal malabsorption, pancreatic
pseudocysts, peri-pancreatic ascites and fistulae, and
duodenal and biliary obstruction [15]. Patients with
chronic pancreatitis frequently present with clinical
episodes of acute pancreatitis [4].
Over the past two decades, hospital admissions due to
both acute and chronic pancreatitis have been steadily
increasing [6, 8]. Despite major advances in intensive
care units and other supportive treatments, the overall
mortality rate from pancreatitis continues to be
approximately 2-6% with each admission [1, 8]. The
factors associated with this high rate of mortality have
not been previously assessed on a large-scale basis.
The aim of our study was to identify both patient-
related and hospital course-related factors that are
strongly associated with death due to pancreatitis in
hospitalized patients.
In our study, both univariate and multivariate logistic
regression analysis confirmed several positive
correlations between specific patient-related factors
and inpatient mortality due to pancreatitis. Age greater
than 65 years (OR=2.92, P<0.001) and the presence of
more than 3 comorbid conditions (OR=16.74, P<0.001)
were both strong and independent clinical predictors of
mortality. Furthermore, female gender was associated
with a decreased rate of mortality (OR=0.81, P<0.001),
as were patients of higher economic status in the 2nd
and 3rd
quartiles of household income (OR=0.81,
P=0.004, and OR=0.83, P=0.016 respectively). Lastly,
of the various races analyzed, only African American
race showed significant correlation with pancreatitis-
200
P=0.025). It should be noted that higher income and
African American race (significantly lower mortality
and higher mortality by multivariate analysis,
respectively) were not statistically significant factors
by univariate analysis. This may be due to their
possible interplay with one another, creating somewhat
of a “protective effect” from a positive association with
mortality when each factor is not independently
assessed.
In addition to patient-related factors, we analyzed
hospital course-related characteristics that were
potentially associated with mortality. In both univariate
and multivariate analysis, increasing length of stay was
associated with increasing rates of hospital mortality.
Patients admitted for longer than 14 days were most
likely to die (OR=1.24, P=0.004). Moreover, those
patients that underwent more than one procedure
during their hospitalization were also at greater risk for
inpatient death (OR=5.42, P<0.001).
Other studies have examined the trends in hospital
admissions and mortality due to acute and chronic
pancreatitis [8, 16, 17, 18, 19]. Fagenholz et al. showed
that hospital admissions for acute pancreatitis in the
United States were higher among African Americans
than Whites between the years 1988 and 2003 [8]. The
overall mortality rate was 2%, with increasing age and
male gender comprising two independent risk factors
for hospital death. Our study confirms these findings,
but further highlights the racial disparities among
African Americans and Caucasians with respect to
pancreatitis-related mortality. To our knowledge,
Fagenholz et al. is the only other group that has
previously identified these differences on such a large-
scale, nationwide inpatient study [8]. Furthermore, our
study supports the relatively high overall mortality rate
from pancreatitis (2.7%), and confirms the association
between increasing age and inpatient death.
Why do these differences exist among patients
hospitalized with pancreatitis? One theory is that
patients of minority race and lower socioeconomic
status have poorer access to healthcare and healthcare
coverage [20, 21]. As a result, disease entities such as
pancreatitis frequently present in later stages when the
clinical course is severe, or the associated
complications have already ensued. Later presentation
or transfer from another hospital may translate into a
more complicated hospital course in some settings
[22], with an increased number of hospital procedures,
length of stay, and overall mortality.
This concept of racial or economic disparities in
hospitalized patients, however, is not unique when it
Figure 1. ROC curve for the final predictive model.
0.00
0.2
5
0.50
0.7
5
1.00
Se
n
s
itiv
ity
0.00
0.25
0.50
0.75
1.00
1 - Specificity
Area under ROC curve = 0.8281

Page 6
JOP. J Pancreas (Online) 2009 Mar 9; 10(2):174-180.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 2 - March 2009. [ISSN 1590-8577]
179
comes to gastrointestinal-related diseases. Nguyen et
al. reported colectomy rates to be significantly lower in
African-American patients hospitalized with ulcerative
colitis compared to Caucasians [23]. This same group
reported lower rates of bowel resection in minority
patients hospitalized with Crohn’s disease, and lower
in-hospital mortality for wealthier individuals that
resided in neighborhoods with a median household
income above the national average [24]. Carbonell et
al. analyzed over 93,000 cholecystectomy patients and
demonstrated increasing length of stay in patients with
lower household incomes [25]. Furthermore, Medicare
and Medicaid insured patients had a higher length of
stay, greater total charges, and higher rates of
morbidity and mortality compared to privately-insured
patients that were undergoing bariatric surgical
procedures [26]. Despite these additional reports, racial
and economic disparities in hospital mortality from
pancreatitis have not been previously demonstrated.
Our study shows significant differences in outcomes
for minority and low-income patients, and it highlights
a potential inequality of care in these subsets
presenting with pancreatitis.
In terms of hospital-course characteristics associated
with pancreatitis-related death, our study showed that
greater length of stay and higher numbers of inpatient
procedures were independent predictors of mortality.
Length of stay in acute pancreatitis has been examined
in the past, yet done so in the context of clinical factors
that predict length of stay longer than seven days [27].
Length of stay and inpatient mortality, however, has
not been previously studied, and our results suggest a
higher risk of death with hospital stays greater than two
weeks. Patients that fall into this category are likely
those with severe acute pancreatitis and single-organ
failure, or chronic pancreatitis with an associated
complication. Patients with early severe acute
pancreatitis and multi-organ failure often die within the
first week of hospitalization [28, 29], and therefore
likely comprise only a small minority of patients in our
study that were alive longer than 14 days. In addition,
inpatient procedures such as central line insertion,
endoscopic retrograde cholangiopancreatography
(ERCP), or catheter placement are often performed in
patients with more severe disease, thus translating into
a more complicated hospital course with a higher
likelihood of mortality.
Our final predictive model incorporated the seven
factors by multivariate analysis that proved to be the
statistically significant risk factors for pancreatitis-
related death (age greater than 65 years, male gender,
African American race, more than 3 additional
diagnoses, low income, more than one hospital
procedure, and length of stay greater than 14 days).
Applying these risk factors, the model itself proved to
be robust, with a good accuracy (AUC value of 0.828).
This suggests good predictive value for estimating
inpatient mortality in this subset of hospitalized
patients admitted with pancreatitis.
The main limitation of our study stems from its
retrospective design. It was not a prospective clinical
trial with randomization and longitudinal follow-up.
Instead we analyzed a single database with information
accumulated from hundreds of hospitals around the
country, grouping patients under the umbrella
diagnosis of pancreatitis. As such, we are limited in
both the extent and type of information available for
each patient’s hospitalization. For example, specific
information regarding the type of pancreatitis (i.e.,
acute vs. acute on chronic), patient body mass index
(BMI), the presence of pancreatic necrosis, and/or the
different types of inpatient procedures performed
would be more helpful in our analysis, thus providing
useful clinical correlates to specific factors involved in
limiting overall and procedure-related mortality.
Despite these clear limitations, the study encompasses
a large population of patients with pancreatitis, and
uncovers important patient-related and hospital-related
characteristics that may contribute to inpatient
mortality.
Overall, the results of our analysis suggest that several
factors are associated with pancreatitis-related death in
hospitalized patients. No single characteristic can
reliably or accurately predict mortality, but rather a
combination of factors (both patient-related and
hospital course-related) should be used to predict
inpatient death. In summary, our findings suggest that
older age (more than 65-year-old), male gender,
African American race, low household income, and a
high number of coexisting medial conditions are the
most important patient-related factors in predicting
death from pancreatitis. At the same time, hospital
course-related factors such as a prolonged stay (more
than 14 days) and inpatient procedures (more than one
procedure) are also strongly associated with mortality
and should be used in combination with patient-related
factors to predict pancreatitis-related death in
hospitalized patients.
Awards/recognition The abstract from this manuscript
was presented as an “AGA Poster of Distinction” at
Digestive Disease Week (DDW) 2008 in San Diego,
CA, USA
Grant support None
Study sponsor None
Financial disclosures None of the authors of this
manuscript have any relevant financial disclosures or
conflicts of interest to state
References
1. Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J
Med 2006; 354:2142-50. [PMID 16707751]
2. Venneman NG, Buskens E, Besselink MG, Stads S, Go PM,
Bosscha K, et al. Small gallstones are associated with increased risk
of acute pancreatitis: potential benefits of prophylactic

Page 7
JOP. J Pancreas (Online) 2009 Mar 9; 10(2):174-180.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 2 - March 2009. [ISSN 1590-8577]
180
cholecystectomy? Am J Gastroenterol 2005; 100:2540-50. [PMID
16279912]
3. Lankisch PG, Lowenfels AB, Maisonneuve P. What is the risk
of alcoholic pancreatitis in heavy drinkers? Pancreas 2002; 25:411-2.
[PMID 12409838]
4. Chari ST. Chronic pancreatitis: classification, relationship to
acute pancreatitis, and early diagnosis. J Gastroenterol 2007; 42:58-
9. [PMID 17238029]
5. Nair RJ, Lawler L, Miller MR. Chronic pancreatitis. Am Fam
Physician 2007; 76:1679-88. [PMID 18092710]
6. Spanier BW, Dijkgraaf MG, Bruno MJ. Epidemiology, aetiology
and outcome of acute and chronic pancreatitis: An update. Best Pract
Res Clin Gastroenterol 2008; 22:45-63. [PMID 18206812]
7. DeFrances CJ, Hall MJ, Podgornik MN. 2003 National Hospital
Discharge Survey. Advance data from vital and health statistics. No.
359. Hyattsville, MD: National Center for Health Statistics, 2005.
8. Fagenholz PJ, Castillo CF, Harris NS, Pelletier AJ, Camargo CA
Jr. Increasing United States hospital admissions for acute
pancreatitis, 1988-2003. Ann Epidemiol 2007; 17:491-7. [PMID
17448682]
9. McKay CJ, Imrie CW. The continuing challenge of early
mortality in acute pancreatitis. Br J Surg 2004; 91:1243-4. [PMID
15382103]
10. Forsmark CE, Toskes PP. Acute pancreatitis. Medical
management. Crit Care Clin 1995; 11:295-309. [PMID 7788533]
11. Winslet M, Hall C, London NJ, Neoptolemos JP. Relation of
diagnostic serum amylase levels to aetiology and severity of acute
pancreatitis. Gut 1992; 33:982-6. [PMID 1379569]
12. Corfield AP, Cooper MJ, Williamson RC. Acute pancreatitis: a
lethal disease of increasing incidence. Gut 1985; 26:724-9. [PMID
4018637]
13. de Beaux AC, Palmer KR, Carter DC. Factors influencing
morbidity and mortality in acute pancreatitis; an analysis of 279
cases. Gut 1995; 37:121-6. [PMID 7672660]
14. Neoptolemos JP, Raraty M, Finch M, Sutton R. Acute
pancreatitis: the substantial human and financial costs. Gut 1998;
42:886-91. [PMID 9691932]
15. Steer ML, Waxman I, Freedman S. Chronic pancreatitis. N Engl
J Med 1995; 332:1482-90. [PMID 7739686]
16. Frey CF, Zhou H, Harvey DJ, White RH. The incidence and
case-fatality rates of acute biliary, alcoholic, and idiopathic
pancreatitis in California, 1994-2001. Pancreas 2006; 33:336-44.
[PMID 17079936]
17. Lindkvist B, Appelros S, Manjer J, Borgström A. Trends in
incidence of acute pancreatitis in a Swedish population: is there
really an increase? Clin Gastroenterol Hepatol 2004; 2:831-7. [PMID
15354285]
18. Eland IA, Sturkenboom MJ, Wilson JH, Stricker BH. Incidence
and mortality of acute pancreatitis between 1985 and 1995. Scand J
Gastroenterol 2000; 35:1110-6. [PMID 11099067]
19. Floyd A, Pedersen L, Nielsen GL, Thorladcius-Ussing O,
Sorensen HT. Secular trends in incidence and 30-day case fatality of
acute pancreatitis in North Jutland County, Denmark: a register-
based study from 1981-2000. Scand J Gastroenterol 2002; 37:1461-5.
[PMID 12523598]
20. Dark CK, Ezenkwele UA. Access to care as a predictor of
patients' knowledge of cardiovascular diseases. J Natl Med Assoc
2007; 99:1338-46. [PMID 18229770]
21. Arthur M, Hedges JR, Newgard CD, Diggs BS, Mullins RJ.
Racial disparities in mortality among adults hospitalized after injury.
Med Care 2008; 46:192-9. [PMID 18219248]
22. Hill AD, Vingilis E, Martin CM, Hartford K, Speechley KN.
Interhospital transfer of critically ill patients: demographic and
outcomes comparison with nontransferred intensive care unit
patients. J Crit Care 2007; 22:290-5. [PMID 18086399]
23. Nguyen GC, Laveist TA, Gearhart S, Bayless TM, Brant SR.
Racial and geographic variations in colectomy rates among
hospitalized ulcerative colitis patients. Clin Gastroenterol Hepatol
2006; 4:1507-13. [PMID 17162242]
24. Nguyen GC, Bayless TM, Powe NR, Laveist TA, Brant SR.
Race and health insurance are predictors of hospitalized Crohn's
disease patients undergoing bowel resection. Inflamm Bowel Dis
2007; 13:1408-16. [PMID 17567876]
25. Carbonell AM, Lincourt AE, Kercher KW, Matthews BD, Cobb
WS, Sing RF, Heniford BT. Do patient or hospital demographics
predict cholecystectomy outcomes? A nationwide study of 93,578
patients. Surg Endosc 2005; 19:767-73. [PMID 15868259]
26. Carbonell AM, Lincourt AE, Matthews BD, Kercher KW, Sing
RF, Heniford BT. National study of the effect of patient and hospital
characteristics on bariatric surgery outcomes. Am Surg 2005;
71:308-14. [PMID 15943404]
27. Pofahl WE, Walczak SM, Rhone E, Izenberg SD. Use of an
artificial neural network to predict length of stay in acute
pancreatitis. Am Surg 1998; 64:868-72. [PMID 9731816]
28. Isenmann R, Rau B, Beger HG. Early severe acute pancreatitis:
characteristics of a new subgroup. Pancreas 2001; 22:274-8. [PMID
11291929]
29. Beger HG, Rau BM. Severe acute pancreatitis: Clinical course
and management. World J Gastroenterol 2007; 13:5043-51. [PMID
17876868]

There are no products listed under this category.