Dermatology: Practical and Conceptual Opinion | Dermatol Pract Concept. 2023;13(4):e2023214 1 Adult Burn Inpatients Have Increased Burn Severity and Mortality Compared to Children in Retrospective Analysis of National Inpatient Sample 2017 Amar D. Desai1, Noelle Desir2, Shari R. Lipner3 1 Rutgers New Jersey Medical School, Newark, NJ, USA 2 Weill Cornell Medical College, New York, NY, USA 3 Department of Dermatology, Weill Cornell Medicine, New York, NY, USA Citation: Desai AD, Desir N, Lipner SR. S Adult Burn Inpatients Have Increased Burn Severity And Mortality Compared To Children In Retrospective Analysis Of National Inpatient Sample 2017. Dermatol Pract Concept. 2023;13(4):e2023214. DOI: https://doi.org/10.5826/ dpc.1304a214 Accepted: April 8, 2023; Published: October 2023 Copyright: ©2023 Desai et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: Mr. Desai and Ms. Desir have no conflicts of interest. Dr. Lipner has served as a consultant for Orth-Dermatologics, Verrica, Moberg Pharmaceuticals, and Hoth Therapeutics. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Shari R. Lipner, MD, PhD, Associate Professor of Clinical Dermatology Weill Cornell Medicine, 1305 York Avenue, 9th Floor, New York, NY 10012, (646) 962-3376 Email: shl9032@med.cornell.edu Introduction: Socioeconomic status and comorbidities are associated with increased mortality in pa- tients with external surface burn patients, however differences between pediatric and adult burn pop- ulations have not been adequately studied. Objectives: Our objectives were to explore the presentation, management, and outcomes of external surface burns across age groups. Methods: The 2017 National Inpatient Sample (NIS) was queried for patients with any diagnosis of external body surface burns. Demographics, comorbidities, complications, total charges, length of stay (LOS), number of procedures undergone (NPU), and time from admission to first procedure (TFP) were identified. Univariate and multivariable analyses were used to identify statistical associations with age. Results: 52,335 inpatients were identified with burns, with the majority male (63.6%) and adults (81.8%). Mean age was 50.5 (standard error [SE] 0.1) and 5.5 (SE 0.1) years for adults and children, respectively. Adults had higher prevalence of hypertensive disease (43.5% versus. 1.4%), diabetes mellitus (24.1% versus 0.3%), and obesity (11.7% versus 1.6%) than children (P < 0.001). Adults versus children had higher odds for mortality (odds ratio [OR] 4.26, 95% confidence interval [CI] 3.08–5.89), sepsis (OR 5.16, 95% CI 4.10–6.48), and pneumonia (OR 4.26, 95% CI 3.30–5.50). ABSTRACT 2 Opinion | Dermatol Pract Concept. 2023;13(4):e2023214 Introduction Burn injury is a significant public health concern, with the World Health Organization estimating 180,000 burn related deaths globally [1]. Socioeconomic status and comorbidities are associated with increased mortality in external surface burn patients of all ages [2,3]; however, differences in the impact of demographics, including comorbidity burden, be- tween pediatric and adult burn populations has not been adequately studied. We performed a retrospective analysis of inpatients with external surface burns comparing pre- sentation, management, and outcomes between children and adults. Methods The 2017 National Inpatient Sample (NIS), a nationally rep- resentative database of all non-Federal hospital stays, was queried for patients with any diagnosis of external body surface burns by ICD-10 code (T20.0-3, T21.0-3, T22.0-3, T23.0-3, T24.0-3, and T25.0-3) [4]. NIS uses the All Patient Refined DRGs (APR-DRG) classification system to catego- rize severity of illness as minor, moderate, major, or extreme loss of function (LOF). Age identified children (younger than 18 years) and adults (18 years or older). Demographics (sex, race, median income, primary payer status, hospital region), comorbidities, complications, total charges, length of stay (LOS), number of procedures undergone (NPU), and time from admission to first procedure (TFP) were identified. Univariate and multivariable analyses were used to identify statistical associations with age with P < 0.05 considered sta- tistically significant. Results There were 52,335 inpatients identified with burns, with the majority being males (63.6%), white (58.7%), and adults (81.8%) (Table 1). Mean patient age was 50.5 (SE: 0.1) and 5.5 (standard error [SE] 0.1) years for adults and children, respectively (Table 1). A greater proportion of children ver- sus adults were in the lowest income quartile and a greater proportion of adults vs. children were in the highest in- come quartile (P < 0.001) (Table 1). The majority of pedi- atric patients were Medicaid insured (59.2% versus 24.6%) (P < 0.001). Adults versus children were more likely to have major LOF (33.5% versus 13.6%) (P < 0.001) (Table 1). Adults had higher incidence of hypertension (43.5% ver- sus 1.4%), diabetes mellitus (24.1% versus 0.3%), anemia (21.5% versus 3.9%), hyperlipidemia (18.7% versus 0.1%), chronic pulmonary disease (18.0% versus 6.3%), obesity (11.7 versus1.6%), and heart failure (9.5% versus 0.3%) than children (P < 0.001) (Table 1). Adult versus pediatric burn patients with obesity and diabetes had greater odds of mortality (P < 0.001) (Table 1). On multivariable analyses, adjusting for demographics, hospital data, and comorbidities, adults had greater total charges ($125,444 versus $91,244), LOS (8.7 versus 6.6 days), and TFP (2.6 versus 1.8 days) but underwent slightly fewer procedures (3.4 versus 3.6 procedures) than children (P < 0.015) (Table 2). Adults had higher odds of mortality (odds ratio [OR] 4.26, 95% confidence interval [CI] 3.08– 5.89), sepsis (OR 5.16, 95% CI 4.10–6.48), pneumonia (OR 4.26, 95% CI 3.30–5.50) than children (P < 0.001) (Table 3). Conclusions In this retrospective study of 52,335 inpatients with burns, we found that the majority were male, burns were four times more common in adults, and adults more often had comor- bidities, complications, greater odds of mortality, and expe- rienced more severe burns and LOF than children. Children versus adults were more likely to be in the lowest income quartile and Medicaid insured. Our findings that most burn patients were adult men was consistent with a cross-sectional retrospective analysis of 97,986 cases of burn injuries in the National Electronic Injury Surveillance System (NEISS) 2000-2018 reporting that 51.6% of patients were adults and 54% were men [5]. Similarly, another cross-sectional NEISS retrospective study 2000-2018 reported that adult versus pediatric patients (80.16% versus 19.81%) comprised the vast majority of pa- tients with fire and flame burns [6]. We found that adult versus pediatric burn patients with obesity and diabetes had greater odds of mortality. Similarly, diabetic and obese burn patients had 2.38 higher odds of mortality than non-diabetic and non-obese patients in a systematic review and meta-analysis [7]. In a retrospective case-control study of 5332 adult burn patients admitted to Conclusions: In this national cohort of inpatients with external surface burns, comorbidities, and odds for mortality and complications varied by age. Pediatric patients more often had lower household incomes; however, adults had significantly higher odds for mortality suggesting that age and comor- bidity status are more impactful on burn outcomes than socioeconomic status. Opinion | Dermatol Pract Concept. 2023;13(4):e2023214 3 a regional burn center 2002-2012, preexisting cardiovascu- lar disease was associated with a 33% increase in intensive care unit admission (incidence rate ratio [IRR] =1.33, 95% CI=1.22–1.47) and 42% increased mortality (IRR=1.42, 95% CI=1.10–1.84) [8]. Adults versus children in our study more often had heart failure and coagulation defects, which may explain increased odds of mortality in adults. Simi- larly, in another retrospective case-control study of 5480 burn patient admissions 2016-2018, those with neurolog- ical disorders, diabetes, hypertension, and psychoses, had increased risk of complications and death [9]. In our mul- tivariable analyses, adults versus children had higher rates Table 1. Demographic data of patients with burns by age group (%). Pediatric (< 18 years) Adult ( ≥ 18 years) Total P value N = 9535 (18.2%) N = 42800 (81.8%) N = 52335 Age Age, years (mean [SE]) 5.49 [0.06] 50.50 [0.09] 42.30 [0.11] < 0.001 Sex Male 59.7 64.4 63.6 < 0.001 Female 40.3 35.6 36.4 Race White 41.5 62.5 58.7 < 0.001 Black 26.3 17.6 19.2 Hispanic 20.4 12.2 13.7 Other 11.9 7.7 8.5 Median Income Quartile - Patient Zip Code 0 – 25 39.5 37.6 37.9 < 0.001 26 – 50 27.8 27.3 27.4 51 – 75 19.7 20.4 20.3 76 – 100 13.0 14.7 14.4 Primary Payer Status Medicare 0.2 33.5 27.4 < 0.001 Medicaid 59.2 24.6 30.9 Private Insurance 29.1 23.1 24.2 Other 11.5 18.8 17.5 Hospital Region Northeast 18.6 15.6 16.2 < 0.001 Midwest 19.6 21.2 20.9 South 41.7 41.3 41.4 West 20.1 21.8 21.5 Severity of Illness Subclass (Loss of Function) Minor LOF 51.0 17.9 23.9 < 0.001 Moderate LOF 29.9 35.5 34.5 Major LOF 13.6 33.5 29.9 Extreme LOF 5.5 13.0 11.7 Comorbidity Anemia 3.9 21.5 18.3 < 0.001 Heart Failure 0.3 9.5 7.8 < 0.001 Chronic Pulmonary Disease 6.3 18.0 15.9 < 0.001 Coagulation Defect 1.0 5.5 4.7 < 0.001 Diabetes Mellitus 0.3 24.1 19.8 < 0.001 Hypertensive Disease 1.4 43.5 35.8 < 0.001 Fluid and Electrolyte Disorders 6.0 26.2 22.5 < 0.001 Obesity 1.6 11.7 9.9 < 0.001 Renal Failure 0.0 9.5 7.8 < 0.001 Lipidemia 0.1 18.7 15.3 < 0.001 Mood (affective) Disorders 2.7 39.1 32.5 < 0.001 Dermatitis and Eczema 3.2 1.5 1.8 < 0.001 LOF = loss of function. 4 Opinion | Dermatol Pract Concept. 2023;13(4):e2023214 burn clinics, or those who did not seek medical care were excluded. It does not specify burn location (ie face) and treatment data. Cases were retrospectively reported without dermatologist confirmation, limiting our analysis. We found that most burn inpatients were adults and have higher rates of complications and mortality than children, which may be explained by adults higher incidence of severe burns, represented by increased incidence of major or ex- treme LOF, and comorbidities. Although pediatric patients more often had lower household incomes, they had better outcomes than adults, suggesting that age and comorbidity status are more impactful on burn outcomes. Therefore, we recommend that dermatologists consider patient age and co- morbidity status when managing burns and need for burn unit referral. References 1. World Health Organization. World Health Organization; [cited 2022Dec8]. Burns. 2022. Available from: https://www.who.int /news-room/fact-sheets/detail/burns, Accessed on December 8, 2022. 2. Bedri H, Romanowski KS, Liao Jet al. A National Study of the Effect of Race, Socioeconomic Status, and Gender on Burn of complications and mortality, which may be due to adults having more comorbidities. We found a statistically significant difference in income distribution for pediatric versus adult patients by zip code. Primary payer status can be used as a proxy for income and the primary payer for most pediatric patients was Medicaid. Since Medicaid qualifications require household incomes be- low the federal poverty level, most pediatric burn patients lived in low-income households, regardless of zip code. In a retrospective case-control study of 135,680 patient records from the National Burn Repository 2002-2011, uninsured status was used as a proxy for lower socioeconomic sta- tus and was correlated with higher mortality rate (OR 1.3, P = .007) and longer LOS (OR 1.3, P < .001) for burn pa- tients [2]. However, despite pediatric burn patients being more likely to live in low-income households, we found that adult burn patients suffered higher rates of morbidity and mortality. Our findings suggest that the higher burden of co- morbidities and complications in adult versus pediatric burn patients play a more significant role than socioeconomic sta- tus in predicting patient outcomes. The NIS database only reports inpatient cases, therefore burn patients who presented to urgent care, primary care, Table 2. Management, charges, and outcomes of patients with burns by age group. Pediatric(< 18 years) Adult( ≥ 18 years) Total P value Total Charges Charges ($) (mean [SE]) 91,243.77 [3,554.80] 125,444.41 [1,603.87] 119,261.90 [1,463.79] < 0.001 Length of Stay Number of Days (mean [SE]) 6.64 [0.15] 8.69 [0.07] 8.32 [0.06] < 0.001 Number of Procedures Number of Procedures (mean [SE]) 3.64 [0.05] 3.43 [0.02] 3.47 [0.02] < 0.001 Time Until 1st Procedure Number of Days (mean [SE]) 1.79 [0.05] 2.59 [0.03] 2.44 [0.03] < 0.001 Mortality Mortality Rate (%) 0.6 2.9 2.5 < 0.001 Sepsis Complication Rate (%) 1.0 7.5 6.3 < 0.001 Pneumonia Complication Rate (%) 0.9 5.7 4.8 < 0.001 Respiratory Failure Complication Rate (%) 3.5 12.5 10.9 < 0.001 Skin Subcutaneous Infection Complication Rate (%) 4.1 20.0 17.1 < 0.001 Osteomyelitis Complication Rate (%) 0.2 2.2 1.9 < 0.001 Acute Kidney Failure Complication Rate (%) 0.4 12.9 10.7 < 0.001 Urinary Tract Infection Complication Rate (%) 0.9 6.0 5.1 < 0.001 Hypoxemia Procedure Rate (%) 0.3 1.7 1.5 < 0.001 Tracheotomy Procedure Rate (%) 0.5 1.9 1.7 < 0.001 Tracheostomy Procedure Rate (%) 2.1 3.9 3.6 < 0.001 Tracheoscopy Procedure Rate (%) 0.9 2.0 1.8 < 0.001 Transfusion Procedure Rate (%) 1.6 3.8 3.4 < 0.001 Ventilation Procedure Rate (%) 0.6 1.2 1.1 < 0.001 Imaging Procedure Rate (%) 1.5 6.0 5.2 < 0.001 Opinion | Dermatol Pract Concept. 2023;13(4):e2023214 5 injuries presenting to United States emergency departments 2000-2018. Burns. 2022;48(6):1347-1354. DOI: 10.1016/j .burns.2021.11.015. PMID: 34924228. 7. Born LJ, Quiroga LH, Lagziel T, Hultman CS, Asif M. Clini- cal outcomes in 'diabese' burn patients: A systematic review and meta-analysis.  Burns. 2022;48(2):281-292. DOI:10.1016/j .burns.2021.04.001 8. Knowlin L, Reid T, Williams F, Cairns B, Charles A. Burn mor- tality in patients with preexisting cardiovascular disease. Burns. 2017;43(5):949-955. DOI:10.1016/j.burns.2017.01.026. PMID: 28189352. PMCID: PMC5912170. 9. Knowlin L, Stanford L, Moore D, Cairns B, Charles A. The measured effect magnitude of co-morbidities on burn injury mortality. Burns. 2016;42(7):1433-1438. DOI: 10.1016/j .burns.2016.03.007. PMID: 27593340. PMCID: PMC5278667. Outcomes. J Burn Care Res. 2017;38(3):161-168. DOI: 10.1097 /BCR.0000000000000416. PMID: 28423388. 3. Lam NN, Duc NM, Hung NT. Influence of pre-existing med- ical condition and predicting value of modified Elixhauser comorbidity index on outcome of burn patients. Burns. 2020;46(2):333-339. DOI:10.1016/j.burns.2019.08. PMID: 31859095. 4. HCUP National Inpatient Sample (NIS). Healthcare Cost and Uti- lization Project (HCUP). 2012. Agency for Healthcare Research and Quality, Rockville, MD.  Available from: www.hcup-us.ahrq| .gov/nisoverview.jsp, Accessed on December 10, 2022. 5. Lee A, Wang Y, Nadarajah C, Lipner S. Scalp and hair burns have high admission rates and disproportionally affect females and children in a cross-sectional analysis of NEISS 2000-2018. Int J Dermatol. 2023;62(5):e281-e283. DOI: 10.1111/ijd.16234. 6. Lee A, Wang Y, Nadarajah CC, Lipner SR. Cross-sectional anal- ysis of national electronic injury surveillance system for burn Table 3. Adjusted multivariable analysis (with marginal values and odds ratios) of management, charges, and outcomes in patients with Burns by age group. Adjusted (Adult versus. reference Child) 95% CI P value Total Charges Charges (marginal $) 23,150.95 14,797.32 to 31,504.57 < 0.001 Length of Stay Length of Stay (marginal days) 1.56 1.22 to 1.90 < 0.001 Number of Procedures Procedures (marginal number) -0.15 -0.27 to -0.03 0.012 Time Until 1st Procedure Time (marginal days) 0.23 0.08 to 0.38 0.002 Mortality Complication (OR) 4.26 3.08 to 5.89 < 0.001 Sepsis Complication (OR) 5.16 4.10 to 6.48 < 0.001 Pneumonia Complication (OR) 4.26 3.30 to 5.50 < 0.001 Respiratory Failure Complication (OR) 2.53 2.22 to 2.89 < 0.001 Skin Subcutaneous Infection Complication (OR) 4.69 4.20 to 5.24 < 0.001 Osteomyelitis Complication (OR) 7.45 4.43 to 12.53 < 0.001 Acute Kidney Failure Complication (OR) 14.18 9.86 to 20.39 < 0.001 Urinary Tract Infection Complication (OR) 3.84 3.04 to 4.84 < 0.001 Hypoxemia Complication (OR) 2.84 1.94 to 4.15 < 0.001 Tracheotomy Procedure (OR) 3.01 2.07 to 4.40 < 0.001 Tracheostomy Procedure (OR) 1.25 1.05 to 1.48 0.011 Tracheoscopy Procedure (OR) 2.09 1.59 to 2.76 < 0.001 Dressing Procedure (OR) 0.46 0.41 to 0.51 < 0.001 Transfusion Procedure (OR) 1.57 1.29 to 1.91 < 0.001 Ventilation Procedure (OR) 0.80 0.58 to 1.10 0.162 Imaging Procedure (OR) 2.05 1.70 to 2.48 < 0.001 Covariables: sex, race, income quartile, primary payer status, hospital region, fluid and electrolyte disorders, hypertensive disease CI = confidence interval; OR = odds ratio.