Simmons Niamh, Olsen Margaret A, Buss Joanna, Bailey Thomas C, Mejia-Chew Carlos
UCD School of Medicine, University College Dublin, Dublin, Ireland.
Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, Missouri, USA.
Open Forum Infect Dis. 2023 Feb 1;10(2):ofad050. doi: 10.1093/ofid/ofad050. eCollection 2023 Feb.
Tuberculosis meningitis (TBM) has high mortality and morbidity. Diagnostic delays can impact TBM outcomes. We aimed to estimate the number of potentially missed opportunities (MOs) to diagnose TBM and determine its impact on 90-day mortality.
This is a retrospective cohort of adult patients with a central nervous system (CNS) TB (ICD-9/10) diagnosis code (013*, A17*) identified in the Healthcare Cost and Utilization Project, State Inpatient and State Emergency Department (ED) Databases from 8 states. Missed opportunity was defined as composite of ICD-9/10 diagnosis/procedure codes that included CNS signs/symptoms, systemic illness, or non-CNS TB diagnosis during a hospital/ED visit 180 days before the index TBM admission. Demographics, comorbidities, admission characteristics, mortality, and admission costs were compared between those with and without a MO, and 90-day in-hospital mortality, using univariate and multivariable analyses.
Of 893 patients with TBM, median age at diagnosis was 50 years (interquartile range, 37-64), 61.3% were male, and 35.2% had Medicaid as primary payer. Overall, 407 (45.6%) had a prior hospital or ED visit with an MO code. In-hospital 90-day mortality was not different between those with and without an MO, regardless of the MO coded during an ED visit (13.7% vs 15.2%, = .73) or a hospitalization (28.2% vs 30.9%, = .74). Independent risk of 90-day in-hospital mortality was associated with older age, hyponatremia (relative risk [RR], 1.62; 95% confidence interval [CI], 1.1-2.4; = .01), septicemia (RR, 1.6; 95% CI, 1.03-2.45; = .03), and mechanical ventilation (RR, 3.4; 95% CI, 2.25-5.3; < .001) during the index admission.
Approximately half the patients coded for TBM had a hospital or ED visit in the previous 6 months meeting the MO definition. We found no association between having an MO for TBM and 90-day in-hospital mortality.
结核性脑膜炎（TBM）的死亡率和发病率都很高。诊断延误可能会影响TBM的治疗结果。我们旨在估计诊断TBM时潜在的错失机会（MO）数量，并确定其对90天死亡率的影响。
这是一项回顾性队列研究，研究对象为在医疗成本与利用项目、8个州的州住院患者数据库和州急诊科（ED）数据库中确定的患有中枢神经系统（CNS）结核病（ICD-9/10）诊断代码（013*，A17*）的成年患者。错失机会被定义为ICD-9/10诊断/程序代码的组合，包括在索引TBM入院前180天的医院/ED就诊期间出现的CNS体征/症状、全身性疾病或非CNS结核病诊断。使用单变量和多变量分析，比较了有和没有MO的患者的人口统计学、合并症、入院特征、死亡率和入院成本，以及90天住院死亡率。
在893例TBM患者中，诊断时的中位年龄为50岁（四分位间距，37-64岁），61.3%为男性，35.2%以医疗补助作为主要支付方。总体而言，407例（45.6%）患者在之前的医院或ED就诊时有MO代码。无论MO是在ED就诊期间（13.7%对15.2%，P =.73）还是住院期间（28.2%对30.9%，P =.74）编码，有和没有MO的患者的90天住院死亡率没有差异。90天住院死亡率的独立风险与年龄较大、低钠血症（相对风险[RR]，1.62；95%置信区间[CI]，1.1-2.4；P =.01）、败血症（RR，1.6；95%CI，1.03-2.45；P =.03）以及索引入院期间的机械通气（RR，3.4；95%CI，2.25-5.3；P <.001）相关。
约一半编码为TBM的患者在之前6个月内有符合MO定义的医院或ED就诊。我们发现TBM的MO与90天住院死亡率之间没有关联。
