10.5826/dpc.1304a214
Introduction: Socioeconomic status and comorbidities are associated with increased mortality in external surface burn patients of all ages, however differences in the impact of demographics between pediatric and adult burn populations has not been adequately studied.
Objective: The purpose of this article is to explore the presentation, management, and outcomes of external surface burns between different 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 (SE: 0.1) and 5.5 (SE: 0.1) years for adults and children, respectively. Adults had higher incidence of hypertensive disease (43.5% vs. 1.4%), diabetes mellitus (24.1% vs. 0.3%), and obesity (11.7% vs. 1.6%) than children (p&lt;0.001). Adults vs. children had higher odds for mortality (OR 4.26, 95% 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).
Conclusion: In a national cohort of inpatients with external surface burns, total charges, LOS, NPU, TFP, and odds for complications varied by age. Pediatric patients more often had lower household incomes; however, adults had significantly higher odds for mortality suggesting that age and comorbidity status are more impactful on burn outcomes than socioeconomic status.
text/xml
2160-9381
3087
en
Shari Lipner
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
adult burn
Adult Burn Inpatients Have Increased Burn Severity and Mortality Compared to Children in a Retrospective Analysis of the 2017 National Inpatient Sample 2017
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Opinion
2023-10-31
2022-12-16
2023-10-31
2024-01-15
e2023214
Dermatol Pract Concept
Introduction: Socioeconomic status and comorbidities are associated with increased mortality in external surface burn patients of all ages, however differences in the impact of demographics between pediatric and adult burn populations has not been adequately studied.
Objective: The purpose of this article is to explore the presentation, management, and outcomes of external surface burns between different 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 (SE: 0.1) and 5.5 (SE: 0.1) years for adults and children, respectively. Adults had higher incidence of hypertensive disease (43.5% vs. 1.4%), diabetes mellitus (24.1% vs. 0.3%), and obesity (11.7% vs. 1.6%) than children (p&lt;0.001). Adults vs. children had higher odds for mortality (OR 4.26, 95% 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).
Conclusion: In a national cohort of inpatients with external surface burns, total charges, LOS, NPU, TFP, and odds for complications varied by age. Pediatric patients more often had lower household incomes; however, adults had significantly higher odds for mortality suggesting that age and comorbidity status are more impactful on burn outcomes than socioeconomic status.
Shari Lipner
2023/10/31
10.5826/dpc.1304a214
e2023214
Department of Dermatology, Weill Cornell Medicine, New York, NY, USA
2160-9381
adult burn
en
e2023214
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.
Adult Burn Inpatients Have Increased Burn Severity and Mortality Compared to Children in a Retrospective Analysis of the 2017 National Inpatient Sample 2017
https://dpcj.org/index.php/dpc/article/download/3087/2362
          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




  ABSTRACT             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).




Opinion | Dermatol Pract Concept. 2023;13(4):e2023214                                                                                       1
                          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.




Introduction                                                         (P < 0.001). Adults versus children were more likely to have
                                                                     major LOF (33.5% versus 13.6%) (P < 0.001) (Table 1).
Burn injury is a significant public health concern, with the         Adults had higher incidence of hypertension (43.5% ver-
World Health Organization estimating 180,000 burn related            sus 1.4%), diabetes mellitus (24.1% versus 0.3%), anemia
deaths globally [1]. Socioeconomic status and comorbidities          (21.5% versus 3.9%), hyperlipidemia (18.7% versus 0.1%),
are associated with increased mortality in external surface          chronic pulmonary disease (18.0% versus 6.3%), obesity
burn patients of all ages [2,3]; however, differences in the         (11.7 versus1.6%), and heart failure (9.5% versus 0.3%)
impact of demographics, including comorbidity burden, be-            than children (P < 0.001) (Table 1). Adult versus pediatric
tween pediatric and adult burn populations has not been              burn patients with obesity and diabetes had greater odds of
adequately studied. We performed a retrospective analysis            mortality (P < 0.001) (Table 1).
of inpatients with external surface burns comparing pre-                On multivariable analyses, adjusting for demographics,
sentation, management, and outcomes between children                 hospital data, and comorbidities, adults had greater total
and adults.                                                          charges ($125,444 versus $91,244), LOS (8.7 versus 6.6
                                                                     days), and TFP (2.6 versus 1.8 days) but underwent slightly
Methods                                                              fewer procedures (3.4 versus 3.6 procedures) than children
                                                                     (P < 0.015) (Table 2). Adults had higher odds of mortality
The 2017 National Inpatient Sample (NIS), a nationally rep-          (odds ratio [OR] 4.26, 95% confidence interval [CI] 3.08–
resentative database of all non-Federal hospital stays, was          5.89), sepsis (OR 5.16, 95% CI 4.10–6.48), pneumonia (OR
queried for patients with any diagnosis of external body             4.26, 95% CI 3.30–5.50) than children (P < 0.001) (Table 3).
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
                                                                     Conclusions
Refined DRGs (APR-DRG) classification system to catego-
rize severity of illness as minor, moderate, major, or extreme       In this retrospective study of 52,335 inpatients with burns,
loss of function (LOF). Age identified children (younger than        we found that the majority were male, burns were four times
18 years) and adults (18 years or older). Demographics (sex,         more common in adults, and adults more often had comor-
race, median income, primary payer status, hospital region),         bidities, complications, greater odds of mortality, and expe-
comorbidities, complications, total charges, length of stay          rienced more severe burns and LOF than children. Children
(LOS), number of procedures undergone (NPU), and time                versus adults were more likely to be in the lowest income
from admission to first procedure (TFP) were identified.             quartile and Medicaid insured.
Univariate and multivariable analyses were used to identify             Our findings that most burn patients were adult men
statistical associations with age with P < 0.05 considered sta-      was consistent with a cross-sectional retrospective analysis
tistically significant.                                              of 97,986 cases of burn injuries in the National Electronic
                                                                     Injury Surveillance System (NEISS) 2000-2018 reporting

Results                                                              that 51.6% of patients were adults and 54% were men [5].
                                                                     Similarly, another cross-sectional NEISS retrospective study
There were 52,335 inpatients identified with burns, with the         2000-2018 reported that adult versus pediatric patients
majority being males (63.6%), white (58.7%), and adults              (80.16% versus 19.81%) comprised the vast majority of pa-
(81.8%) (Table 1). Mean patient age was 50.5 (SE: 0.1) and           tients with fire and flame burns [6].
5.5 (standard error [SE] 0.1) years for adults and children,            We found that adult versus pediatric burn patients with
respectively (Table 1). A greater proportion of children ver-        obesity and diabetes had greater odds of mortality. Similarly,
sus adults were in the lowest income quartile and a greater          diabetic and obese burn patients had 2.38 higher odds of
proportion of adults vs. children were in the highest in-            mortality than non-diabetic and non-obese patients in a
come quartile (P < 0.001) (Table 1). The majority of pedi-           systematic review and meta-analysis [7]. In a retrospective
atric patients were Medicaid insured (59.2% versus 24.6%)            case-control study of 5332 adult burn patients admitted to



2                                                                               Opinion | Dermatol Pract Concept. 2023;13(4):e2023214
                      Table 1. Demographic data of patients with burns by age group (%).
                                                                        Pediatric         Adult
                                                                      (< 18 years)    ( ≥ 18 years)      Total       P value
                                                                       N = 9535        N = 42800      N = 52335
                                                                       (18.2%)          (81.8%)
                                 Age, years                               5.49           50.50          42.30
 Age                                                                                                                 < 0.001
                                 (mean [SE])                             [0.06]          [0.09]         [0.11]
                                 Male                                     59.7            64.4           63.6
 Sex                                                                                                                 < 0.001
                                 Female                                   40.3            35.6           36.4
                                 White                                    41.5            62.5           58.7
                                 Black                                    26.3            17.6           19.2
 Race                                                                                                                < 0.001
                                 Hispanic                                 20.4            12.2           13.7
                                 Other                                    11.9            7.7             8.5
                                 0 – 25                                   39.5            37.6           37.9
 Median Income                   26 – 50                                  27.8            27.3           27.4
                                                                                                                     < 0.001
 Quartile - Patient Zip Code     51 – 75                                  19.7            20.4           20.3
                                 76 – 100                                 13.0            14.7           14.4
                                 Medicare                                 0.2             33.5           27.4
                                 Medicaid                                 59.2            24.6           30.9
 Primary Payer Status                                                                                                < 0.001
                                 Private Insurance                        29.1            23.1           24.2
                                 Other                                    11.5            18.8           17.5
                                 Northeast                                18.6            15.6           16.2
                                 Midwest                                  19.6            21.2           20.9
 Hospital Region                                                                                                     < 0.001
                                 South                                    41.7            41.3           41.4
                                 West                                     20.1            21.8           21.5
                                 Minor LOF                                51.0            17.9           23.9
 Severity of Illness Subclass    Moderate LOF                             29.9            35.5           34.5
                                                                                                                     < 0.001
 (Loss of Function)              Major LOF                                13.6            33.5           29.9
                                 Extreme LOF                              5.5             13.0           11.7
                                 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
 Comorbidity
                                 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.



a regional burn center 2002-2012, preexisting cardiovascu-         may explain increased odds of mortality in adults. Simi-
lar disease was associated with a 33% increase in intensive        larly, in another retrospective case-control study of 5480
care unit admission (incidence rate ratio [IRR] =1.33, 95%         burn patient admissions 2016-2018, those with neurolog-
CI=1.22–1.47) and 42% increased mortality (IRR=1.42,               ical disorders, diabetes, hypertension, and psychoses, had
95% CI=1.10–1.84) [8]. Adults versus children in our study         increased risk of complications and death [9]. In our mul-
more often had heart failure and coagulation defects, which        tivariable analyses, adults versus children had higher rates



Opinion | Dermatol Pract Concept. 2023;13(4):e2023214                                                                          3
             Table 2. Management, charges, and outcomes of patients with burns by age group.
                                                                 Pediatric(<        Adult( ≥ 18
                                                                  18 years)           years)              Total        P value
 Total Charges                        Charges ($)                91,243.77          125,444.41        119,261.90       < 0.001
                                      (mean [SE])                [3,554.80]         [1,603.87]        [1,463.79]
 Length of Stay                       Number of Days                 6.64               8.69              8.32         < 0.001
                                      (mean [SE])                   [0.15]             [0.07]            [0.06]
 Number of Procedures                 Number of Procedures           3.64               3.43              3.47         < 0.001
                                      (mean [SE])                   [0.05]             [0.02]            [0.02]
 Time Until 1st Procedure             Number of Days                 1.79               2.59              2.44         < 0.001
                                      (mean [SE])                   [0.05]             [0.03]            [0.03]
 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



of complications and mortality, which may be due to adults      burn clinics, or those who did not seek medical care were
having more comorbidities.                                      excluded. It does not specify burn location (ie face) and
    We found a statistically significant difference in income   treatment data. Cases were retrospectively reported without
distribution for pediatric versus adult patients by zip code.   dermatologist confirmation, limiting our analysis.
Primary payer status can be used as a proxy for income and          We found that most burn inpatients were adults and have
the primary payer for most pediatric patients was Medicaid.     higher rates of complications and mortality than children,
Since Medicaid qualifications require household incomes be-     which may be explained by adults higher incidence of severe
low the federal poverty level, most pediatric burn patients     burns, represented by increased incidence of major or ex-
lived in low-income households, regardless of zip code. In a    treme LOF, and comorbidities. Although pediatric patients
retrospective case-control study of 135,680 patient records     more often had lower household incomes, they had better
from the National Burn Repository 2002-2011, uninsured          outcomes than adults, suggesting that age and comorbidity
status was used as a proxy for lower socioeconomic sta-         status are more impactful on burn outcomes. Therefore, we
tus and was correlated with higher mortality rate (OR 1.3,      recommend that dermatologists consider patient age and co-
P = .007) and longer LOS (OR 1.3, P < .001) for burn pa-        morbidity status when managing burns and need for burn
tients [2]. However, despite pediatric burn patients being      unit referral.
more likely to live in low-income households, we found that
adult burn patients suffered higher rates of morbidity and      References
mortality. Our findings suggest that the higher burden of co-
                                                                 1. World Health Organization. World Health Organization; [cited
morbidities and complications in adult versus pediatric burn
                                                                    2022Dec8]. Burns. 2022. Available from: https://www.who.int
patients play a more significant role than socioeconomic sta-
                                                                    /news-room/fact-sheets/detail/burns, Accessed on December 8,
tus in predicting patient outcomes.                                 2022.
    The NIS database only reports inpatient cases, therefore     2. Bedri H, Romanowski KS, Liao Jet al. A National Study of
burn patients who presented to urgent care, primary care,           the Effect of Race, Socioeconomic Status, and Gender on Burn



4                                                                            Opinion | Dermatol Pract Concept. 2023;13(4):e2023214
   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                                       23,150.95                  14,797.32 to       < 0.001
                                    (marginal $)                                                              31,504.57
 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.




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Opinion | Dermatol Pract Concept. 2023;13(4):e2023214                                                                                     5
