International Journal of Cardiology 187 (2015) 542–544
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Ethnic variations in length of hospital stay in patients with atrial fibrillation Ramakrishna S. Gorantla a, Manojna Nimmagadda b, Siri Potluri c, Hardeep Uppal a, Suresh Chandran d, Rahul Potluri a,⁎ a
Department of Internal Medicine, Bassett Medical center, Columbia University of Physicians and Surgeons, Cooperstown, USA ACALM Study Unit in Collaboration with Aston Medical School, Aston University, Birmingham, UK School of Medicine, Cardiff University, Cardiff, UK d Department of Acute Medicine, North Western Deanery, UK b c
a r t i c l e
i n f o
Article history: Received 26 March 2015 Accepted 28 March 2015 Available online 30 March 2015 Keywords: Atrial fibrillation Length of hospital stay Ethnic South Asian
Dear Editor, Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia seen in clinical practice, which places affected patients at an increased risk of mortality, heart failure and thromboembolic events [1,2]. It is a major global burden on the health care system with evidence suggesting an increasing incidence and prevalence [3–5]. A systematic review of world-wide population-based studies (n = 184) has revealed that the age-adjusted prevalence and incidence rates of AF have increased in 2010 compared to 1990 [5]. This study has also revealed that the age-adjusted prevalence rate (per 100,000 population) was highest in North America and lowest in Japan and South Korea. The rate in China was also relatively low. The traditional frequent risk factors known to be associated with AF are hypertension and hypertensive heart disease, coronary heart disease, heart failure, rheumatic heart disease, valvular heart disease including both stenotic and regurgitant lesions, hyperthyroidism, chronic heavy alcohol use etc.
⁎ Corresponding author at: Honorary Clinical Lecturer in Cardiology, Aston University, Aston Triangle, Birmingham B4 7ET, UK. E-mail address: [email protected] (R. Potluri).
http://dx.doi.org/10.1016/j.ijcard.2015.03.405 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
The impact of race on the risk of developing AF has been evaluated in multiple population-based studies that have found that this risk is lower in Blacks compared to Whites [6]. However it has not been determined whether this is because Blacks are at a lower risk or Whites at a higher risk. Another study that included nearly 14,000,000 patients, done in California (United States) between 2005 and 2009 evaluated the relationship between race and incident AF. After adjustments were made for known AF risk factors and patient demographics it was found that, compared to Whites, Blacks (hazard ratio [HR] 0.84), Hispanics (HR 0.78), and Asians (HR 0.78) each had a lower AF risk [7]. According to a recent study done in US, the hospitalization rates for AF have increased exponentially from 2000 to 2010 [8]. The total cost of care for AF related hospitalization also increased tremendously over this time frame which places a major burden on the health care expenditure and serves as a reminder that hospitalizations represent the largest part of the total care for AF treatment [8]. It is therefore obvious that, to reduce the economic burden from this major illness, future efforts must focus on limiting hospitalizations and length of stay. Although some of the factors influencing the rate of hospitalization for AF have been discovered, there is no good data identifying the potential factors that influence the actual length of hospital stay. Also most of the studies on AF related hospitalizations have been conducted on a predominantly Caucasian population and do not provide an accurate representation of healthcare needs in the Black and ethnic minority population. In this study we aimed to explore the ethnic variations in the length of hospital stay in a large multi-ethnic population who presented with AF in the North West of England, UK. Using completely anonymous data, we traced adult patients admitted with AF across seven hospitals in the North West of England using the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol between 1st January 2000 and 31st March 2013. The ACALM study used the International Classification of Disease, Version 10 (ICD-10) diagnosis codes and Office of Population Censuses and Surveys Classification of Interventions and Procedures (OPCS-4) to trace patients. Study participants admitted with a diagnosis of any type of AF, as defined by ICD-10 codes (including subsets), were examined by LOS, ethnicity, age, gender, co-morbidities and type of admission. The Caucasian population was used as a reference group, in comparison to other ethnic groups classified as South Asian, Afro-
R.S. Gorantla et al. / International Journal of Cardiology 187 (2015) 542–544
543
Table 1 Characteristics of admissions for patients with atrial fibrillation. Ethnicity
n (%)
Mean age (years)
Male:female ratio
% admitted as emergency
% with co-morbidity
Mean length of stay (days)
Odds ratio for length of staya
All groups Caucasian South Asian Afro-Caribbean Oriental Mixed Other Unknown
42,685 38,052 735 283 107 51 391 3066
74 74 64 68 71 63 70 76
1.05:1 1.05:1 1.31:1 1.08:1 1.23:1 1.43:1 1:1.04 1:1
83.2 83.3% 82.6% 67.8% 67.3% 70.6% 87.5% 83.4%
66.0% 66.2% 67.5% 63.3% 57% 49% 62.4% 64.6%
10.25 10.07 6.46 11.25 10.62 6.92 13.19 12.94
– 1 0.992 (0.986–0.997)⁎ 1.005 (1.001–1.009)⁎ 1.004 (0.995–1.012) 0.998 (0.980–1.015) 1.007 (1.004–1.010)⁎ 1.005 (1.004–1.007)⁎
a Adjusted for age, sex, co-morbidity, ⁎ Statistically significant, p b 0.05.
Caribbean, Oriental, mixed ethnicity, other ethnicity, and unknown ethnicity. The presence of co-morbidity was defined by the presence of any of the top eight causes of mortality in the UK apart from cerebrovascular disease, namely ischaemic heart disease, heart failure, lung cancer, breast cancer, dementia, chronic kidney disease, and chronic obstructive airway disease. Data analysis was performed using SPSS Version 20.0. Variation in the LOS between ethnic groups was analysed by means of a logistic regression model adjusted for age, sex and co-morbidity with the Caucasian ethnic group as the reference. Completely anonymous patient data was used and processed in accordance with local ethical research and development policy. The methodology has been previously described and used by our group and similar methodology has been used by other groups [9–22]. Within the study period, there were 929,465 overnight admissions. Of these, 42,685 (4.5%) were coded for atrial fibrillation using the International Classification of Disease (ICD) code I48 and all subsets of this code. Our results showed that there were a higher proportion of males (51.3%) admitted with atrial fibrillation, as expected, compared to females (48.7%). As previously reported, patients with atrial fibrillation were older, had other co-morbidities (e.g. hypertension, peripheral vascular disease, hypercholesterolemia, cerebral vascular disease, diabetes and smoking) and were more likely to be admitted as an emergency with longer length of stay (mean 10 days versus 20 days) than patients whose admission was not related to atrial fibrillation. Admissions from the Black and other ethnic minority population comprised 10.9% of total admissions with atrial fibrillation, and these patients were significantly younger than the Caucasian population (Table 1). Length of hospital stay was also strikingly shorter among patients of South Asian and mixed race ethnicity. But only the South Asian patient population length of stay, compared to the Caucasian group, remained significant after modelling for differences in age, sex and comorbidities. Length of hospital stay in was significantly longer in AfroCaribbean patients with AF compared to the Caucasian population after adjusting for differences in age, sex and co-morbidities (Table 1). Whilst a novel observation in AF, the shorter length of hospital stay in South Asian patients has been shown by our group and others in conditions such as ischaemic stroke, myocardial infarction, type 2 diabetes mellitus, aortic stenosis and pulmonary embolism [10,11,13,18,20]. Whilst the reasons for a shorter length of stay in the South Asian and mixed ethnicity population are unknown, there is evidence that suggests that less support is offered to the ethnic minority population at the time of discharge and/or that they may be discharged prematurely and consequently have a greater chance of readmission [23]. The possibility that the shorter length of stay in the South Asian and mixed ethnicity population being secondary to inappropriate early discharge warrants further investigation. Conversely, there is also evidence that South Asian and mixed minority populations have a more supportive home environment that facilities earlier discharge [24]. Despite awareness of inequities in health care quality, little is known about strategies that could improve the quality of healthcare for ethnic minority populations. We believe that the results of this study and the
issues it raises may help design and improve care of inpatients with atrial fibrillation in regions with large multi-ethnic populations.
Conflict of interest statement The authors report no relationships that could be construed as a conflict of interest.
References [1] E.J. Benjamin, P.A. Wolf, R.B. D'Agostino, et al., Impact of atrial fibrillation on the risk of death: the Framingham Heart Study, Circulation 98 (1998) 946. [2] S.S. Chugh, J.L. Blackshear, W.K. Shen, et al., Epidemiology and natural history of atrial fibrillation: clinical implications, J. Am. Coll. Cardiol. 37 (2001) 371. [3] G.Y. Lip, C.M. Brechin, D.A. Lane, The global burden of atrial fibrillation and stroke: a systematic review of the epidemiology of atrial fibrillation in regions outside North America and Europe, Chest 142 (2012) 1489. [4] J. Ball, M.J. Carrington, J.J. McMurray, S. Stewart, Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century, Int. J. Cardiol. 167 (2013) 1807. [5] S.S. Chugh, R. Havmoeller, K. Narayanan, et al., Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study, Circulation 129 (2014) 837. [6] G.M. Marcus, A. Alonso, C.A. Peralta, et al., European ancestry as a risk factor for atrial fibrillation in African Americans, Circulation 122 (2010) 2009. [7] T.A. Dewland, J.E. Olgin, E. Vittinghoff, G.M. Marcus, Incident atrial fibrillation among Asians, Hispanics, blacks, and whites, Circulation 128 (2013) 2470. [8] N.J. Patel, A. Deshmukh, S. Pant, et al., Contemporary trends of hospitalization for atrial fibrillation in the United States, 2000 through 2010: implications for healthcare planning, Circulation 129 (2014) 2371. [9] P. Carter, J. Mann, J. Sangha, H. Uppal, A. Natalwala, A. Aziz, et al., The burden of cardiovascular disease amongst psychiatric patients, Int. J. Cardiol. 169 (2013) e65–e66. [10] K.N. Kimani, R. Potluri, A. Natalwala, S. Ghosh, R. Heun, P. Narendran, Length of hospital stay is shorter in black and ethnic minority patients with diabetes, Diabet. Med. 29 (2012) 830–831. [11] N. Khouw, M. Wasim, A. Aziz, H. Uppal, S. Chandran, R. Potluri, Length of hospital stay is shorter in South Asian patients with myocardial infarction, Int. J. Cardiol. 171 (2014) e54–e55. [12] R. Ciputra, Y. Sembiring, O. Prawato, N. Khouw, M. Baig, H. Uppal, et al., Length of stay in hospital is longer in ethnic minority patients after coronary artery bypass surgery, Int. J. Cardiol. 172 (3) (Apr 1 2014) e434–e435. [13] S. Smith, N. Gollop, H. Uppal, S. Chandran, R. Potluri, Length of hospital stay is shorter in South Asian patients with acute pulmonary embolism, Heart Asia 6 (2014) 1–2. [14] P. Carter, G. Rai, A. Aziz, J. Mann, S. Chandran, H. Uppal, R. Potluri, Trends of cardiovascular disease amongst psychiatric patients between 2001 and 2012 in Greater Manchester, UK, Int. J. Cardiol. 173 (3) (May 15 2014) 573–574. [15] R. Teo, N.D. Gollop, M. Baig, H. Uppal, S. Chandran, R. Potluri, The burden and trends of psychiatric co-morbidities amongst patients with cardiomyopathy, Int. J. Cardiol. 174 (2) (Jun 15 2014) 398–399. [16] D. Lavu, H. Uppal, A. Katragadda, A. Ahmed, R. Potluri, Effect of ethnicity on live birth rates after in vitro fertilisation or Intracytoplasmic sperm injection treatment: possible explanations and further observations, BJOG 121 (12) (Nov 2014) 1576–1577. [17] R. Potluri, M. Baig, J.S. Mavi, N. Ali, A. Aziz, H. Uppal, S. Chandran, The role of angioplasty in patients with acute coronary syndrome and previous coronary artery bypass grafting, Int. J. Cardiol. 176 (3) (2014 Oct 20) 760–763. [18] C. Thakker, N.D. Gollop, P. Carter, D. Lavu, H. Uppal, S. Chandran, R. Potluri, Prevalence and length of hospital stay in patients with aortic valve disease is lower amongst South Asians, Int. J. Cardiol. 177 (1) (Nov 15 2014) 34–36. [19] B. Green, N.D. Gollop, M. Baig, H. Uppal, S. Chandran, R. Potluri, Prolonged length of hospital stay in Far-East Asian and Afro-Caribbean patients with cardiomyopathy, Int. J. Cardiol. 176 (1) (Sep 2014) 230–231. [20] R. Potluri, M. Wasim, B. Markandey, A. Kapour, N. Khouw, P. Carter, H. Uppal, S. Chandran, Length of hospital stay is shorter in South Asian patients with ischaemic stroke, Int. J. Cardiol. 187 (6th May 2015) 190–191.
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R.S. Gorantla et al. / International Journal of Cardiology 187 (2015) 542–544
[21] L. Yssennagger, N.D. Gollop, R.S. Gorantla, M. Nimmagadda, S. Potluri, H. Uppal, S. Chandran, R. Potluri, Increasing burden of psychiatric comorbidities amongst patients with Ischaemic Heart Disease, Int. J. Cardiol. 186 (1st may 2015) 200–201. [22] H. Uppal, S. Chandran, R. Potluri, Risk factors for mortality in Down's syndrome, J. Intellect. Disabil. Res. (2015) http://dx.doi.org/10.1111/jir.12196. [23] Carers National Association, ‘You Can take him home now’: Carers' experiences of hospital dischargeAvailable at http://www.carersuk.org/professionals/resources/
research-library/item/517-you-can-take-him-home-now-carers-experiences-ofhospital-dischargeJune 2001 (Last accessed 26 July 2011). [24] Department of Health and Social Services Inspectorate, They look after their own, don't they?Available at http://webarchive.nationalarchives.gov.uk/+/www.dh.gov. uk/en/Publicationsandstatis- tics/Pressreleases/DH_40243321998 (Last accessed 28 July 2011).
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Ethnic variations in length of hospital stay in patients with atrial fibrillation Ramakrishna S. Gorantla a, Manojna Nimmagadda b, Siri Potluri c, Hardeep Uppal a, Suresh Chandran d, Rahul Potluri a,⁎ a
Department of Internal Medicine, Bassett Medical center, Columbia University of Physicians and Surgeons, Cooperstown, USA ACALM Study Unit in Collaboration with Aston Medical School, Aston University, Birmingham, UK School of Medicine, Cardiff University, Cardiff, UK d Department of Acute Medicine, North Western Deanery, UK b c
a r t i c l e
i n f o
Article history: Received 26 March 2015 Accepted 28 March 2015 Available online 30 March 2015 Keywords: Atrial fibrillation Length of hospital stay Ethnic South Asian
Dear Editor, Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia seen in clinical practice, which places affected patients at an increased risk of mortality, heart failure and thromboembolic events [1,2]. It is a major global burden on the health care system with evidence suggesting an increasing incidence and prevalence [3–5]. A systematic review of world-wide population-based studies (n = 184) has revealed that the age-adjusted prevalence and incidence rates of AF have increased in 2010 compared to 1990 [5]. This study has also revealed that the age-adjusted prevalence rate (per 100,000 population) was highest in North America and lowest in Japan and South Korea. The rate in China was also relatively low. The traditional frequent risk factors known to be associated with AF are hypertension and hypertensive heart disease, coronary heart disease, heart failure, rheumatic heart disease, valvular heart disease including both stenotic and regurgitant lesions, hyperthyroidism, chronic heavy alcohol use etc.
⁎ Corresponding author at: Honorary Clinical Lecturer in Cardiology, Aston University, Aston Triangle, Birmingham B4 7ET, UK. E-mail address: [email protected] (R. Potluri).
http://dx.doi.org/10.1016/j.ijcard.2015.03.405 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
The impact of race on the risk of developing AF has been evaluated in multiple population-based studies that have found that this risk is lower in Blacks compared to Whites [6]. However it has not been determined whether this is because Blacks are at a lower risk or Whites at a higher risk. Another study that included nearly 14,000,000 patients, done in California (United States) between 2005 and 2009 evaluated the relationship between race and incident AF. After adjustments were made for known AF risk factors and patient demographics it was found that, compared to Whites, Blacks (hazard ratio [HR] 0.84), Hispanics (HR 0.78), and Asians (HR 0.78) each had a lower AF risk [7]. According to a recent study done in US, the hospitalization rates for AF have increased exponentially from 2000 to 2010 [8]. The total cost of care for AF related hospitalization also increased tremendously over this time frame which places a major burden on the health care expenditure and serves as a reminder that hospitalizations represent the largest part of the total care for AF treatment [8]. It is therefore obvious that, to reduce the economic burden from this major illness, future efforts must focus on limiting hospitalizations and length of stay. Although some of the factors influencing the rate of hospitalization for AF have been discovered, there is no good data identifying the potential factors that influence the actual length of hospital stay. Also most of the studies on AF related hospitalizations have been conducted on a predominantly Caucasian population and do not provide an accurate representation of healthcare needs in the Black and ethnic minority population. In this study we aimed to explore the ethnic variations in the length of hospital stay in a large multi-ethnic population who presented with AF in the North West of England, UK. Using completely anonymous data, we traced adult patients admitted with AF across seven hospitals in the North West of England using the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol between 1st January 2000 and 31st March 2013. The ACALM study used the International Classification of Disease, Version 10 (ICD-10) diagnosis codes and Office of Population Censuses and Surveys Classification of Interventions and Procedures (OPCS-4) to trace patients. Study participants admitted with a diagnosis of any type of AF, as defined by ICD-10 codes (including subsets), were examined by LOS, ethnicity, age, gender, co-morbidities and type of admission. The Caucasian population was used as a reference group, in comparison to other ethnic groups classified as South Asian, Afro-
R.S. Gorantla et al. / International Journal of Cardiology 187 (2015) 542–544
543
Table 1 Characteristics of admissions for patients with atrial fibrillation. Ethnicity
n (%)
Mean age (years)
Male:female ratio
% admitted as emergency
% with co-morbidity
Mean length of stay (days)
Odds ratio for length of staya
All groups Caucasian South Asian Afro-Caribbean Oriental Mixed Other Unknown
42,685 38,052 735 283 107 51 391 3066
74 74 64 68 71 63 70 76
1.05:1 1.05:1 1.31:1 1.08:1 1.23:1 1.43:1 1:1.04 1:1
83.2 83.3% 82.6% 67.8% 67.3% 70.6% 87.5% 83.4%
66.0% 66.2% 67.5% 63.3% 57% 49% 62.4% 64.6%
10.25 10.07 6.46 11.25 10.62 6.92 13.19 12.94
– 1 0.992 (0.986–0.997)⁎ 1.005 (1.001–1.009)⁎ 1.004 (0.995–1.012) 0.998 (0.980–1.015) 1.007 (1.004–1.010)⁎ 1.005 (1.004–1.007)⁎
a Adjusted for age, sex, co-morbidity, ⁎ Statistically significant, p b 0.05.
Caribbean, Oriental, mixed ethnicity, other ethnicity, and unknown ethnicity. The presence of co-morbidity was defined by the presence of any of the top eight causes of mortality in the UK apart from cerebrovascular disease, namely ischaemic heart disease, heart failure, lung cancer, breast cancer, dementia, chronic kidney disease, and chronic obstructive airway disease. Data analysis was performed using SPSS Version 20.0. Variation in the LOS between ethnic groups was analysed by means of a logistic regression model adjusted for age, sex and co-morbidity with the Caucasian ethnic group as the reference. Completely anonymous patient data was used and processed in accordance with local ethical research and development policy. The methodology has been previously described and used by our group and similar methodology has been used by other groups [9–22]. Within the study period, there were 929,465 overnight admissions. Of these, 42,685 (4.5%) were coded for atrial fibrillation using the International Classification of Disease (ICD) code I48 and all subsets of this code. Our results showed that there were a higher proportion of males (51.3%) admitted with atrial fibrillation, as expected, compared to females (48.7%). As previously reported, patients with atrial fibrillation were older, had other co-morbidities (e.g. hypertension, peripheral vascular disease, hypercholesterolemia, cerebral vascular disease, diabetes and smoking) and were more likely to be admitted as an emergency with longer length of stay (mean 10 days versus 20 days) than patients whose admission was not related to atrial fibrillation. Admissions from the Black and other ethnic minority population comprised 10.9% of total admissions with atrial fibrillation, and these patients were significantly younger than the Caucasian population (Table 1). Length of hospital stay was also strikingly shorter among patients of South Asian and mixed race ethnicity. But only the South Asian patient population length of stay, compared to the Caucasian group, remained significant after modelling for differences in age, sex and comorbidities. Length of hospital stay in was significantly longer in AfroCaribbean patients with AF compared to the Caucasian population after adjusting for differences in age, sex and co-morbidities (Table 1). Whilst a novel observation in AF, the shorter length of hospital stay in South Asian patients has been shown by our group and others in conditions such as ischaemic stroke, myocardial infarction, type 2 diabetes mellitus, aortic stenosis and pulmonary embolism [10,11,13,18,20]. Whilst the reasons for a shorter length of stay in the South Asian and mixed ethnicity population are unknown, there is evidence that suggests that less support is offered to the ethnic minority population at the time of discharge and/or that they may be discharged prematurely and consequently have a greater chance of readmission [23]. The possibility that the shorter length of stay in the South Asian and mixed ethnicity population being secondary to inappropriate early discharge warrants further investigation. Conversely, there is also evidence that South Asian and mixed minority populations have a more supportive home environment that facilities earlier discharge [24]. Despite awareness of inequities in health care quality, little is known about strategies that could improve the quality of healthcare for ethnic minority populations. We believe that the results of this study and the
issues it raises may help design and improve care of inpatients with atrial fibrillation in regions with large multi-ethnic populations.
Conflict of interest statement The authors report no relationships that could be construed as a conflict of interest.
References [1] E.J. Benjamin, P.A. Wolf, R.B. D'Agostino, et al., Impact of atrial fibrillation on the risk of death: the Framingham Heart Study, Circulation 98 (1998) 946. [2] S.S. Chugh, J.L. Blackshear, W.K. Shen, et al., Epidemiology and natural history of atrial fibrillation: clinical implications, J. Am. Coll. Cardiol. 37 (2001) 371. [3] G.Y. Lip, C.M. Brechin, D.A. Lane, The global burden of atrial fibrillation and stroke: a systematic review of the epidemiology of atrial fibrillation in regions outside North America and Europe, Chest 142 (2012) 1489. [4] J. Ball, M.J. Carrington, J.J. McMurray, S. Stewart, Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century, Int. J. Cardiol. 167 (2013) 1807. [5] S.S. Chugh, R. Havmoeller, K. Narayanan, et al., Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study, Circulation 129 (2014) 837. [6] G.M. Marcus, A. Alonso, C.A. Peralta, et al., European ancestry as a risk factor for atrial fibrillation in African Americans, Circulation 122 (2010) 2009. [7] T.A. Dewland, J.E. Olgin, E. Vittinghoff, G.M. Marcus, Incident atrial fibrillation among Asians, Hispanics, blacks, and whites, Circulation 128 (2013) 2470. [8] N.J. Patel, A. Deshmukh, S. Pant, et al., Contemporary trends of hospitalization for atrial fibrillation in the United States, 2000 through 2010: implications for healthcare planning, Circulation 129 (2014) 2371. [9] P. Carter, J. Mann, J. Sangha, H. Uppal, A. Natalwala, A. Aziz, et al., The burden of cardiovascular disease amongst psychiatric patients, Int. J. Cardiol. 169 (2013) e65–e66. [10] K.N. Kimani, R. Potluri, A. Natalwala, S. Ghosh, R. Heun, P. Narendran, Length of hospital stay is shorter in black and ethnic minority patients with diabetes, Diabet. Med. 29 (2012) 830–831. [11] N. Khouw, M. Wasim, A. Aziz, H. Uppal, S. Chandran, R. Potluri, Length of hospital stay is shorter in South Asian patients with myocardial infarction, Int. J. Cardiol. 171 (2014) e54–e55. [12] R. Ciputra, Y. Sembiring, O. Prawato, N. Khouw, M. Baig, H. Uppal, et al., Length of stay in hospital is longer in ethnic minority patients after coronary artery bypass surgery, Int. J. Cardiol. 172 (3) (Apr 1 2014) e434–e435. [13] S. Smith, N. Gollop, H. Uppal, S. Chandran, R. Potluri, Length of hospital stay is shorter in South Asian patients with acute pulmonary embolism, Heart Asia 6 (2014) 1–2. [14] P. Carter, G. Rai, A. Aziz, J. Mann, S. Chandran, H. Uppal, R. Potluri, Trends of cardiovascular disease amongst psychiatric patients between 2001 and 2012 in Greater Manchester, UK, Int. J. Cardiol. 173 (3) (May 15 2014) 573–574. [15] R. Teo, N.D. Gollop, M. Baig, H. Uppal, S. Chandran, R. Potluri, The burden and trends of psychiatric co-morbidities amongst patients with cardiomyopathy, Int. J. Cardiol. 174 (2) (Jun 15 2014) 398–399. [16] D. Lavu, H. Uppal, A. Katragadda, A. Ahmed, R. Potluri, Effect of ethnicity on live birth rates after in vitro fertilisation or Intracytoplasmic sperm injection treatment: possible explanations and further observations, BJOG 121 (12) (Nov 2014) 1576–1577. [17] R. Potluri, M. Baig, J.S. Mavi, N. Ali, A. Aziz, H. Uppal, S. Chandran, The role of angioplasty in patients with acute coronary syndrome and previous coronary artery bypass grafting, Int. J. Cardiol. 176 (3) (2014 Oct 20) 760–763. [18] C. Thakker, N.D. Gollop, P. Carter, D. Lavu, H. Uppal, S. Chandran, R. Potluri, Prevalence and length of hospital stay in patients with aortic valve disease is lower amongst South Asians, Int. J. Cardiol. 177 (1) (Nov 15 2014) 34–36. [19] B. Green, N.D. Gollop, M. Baig, H. Uppal, S. Chandran, R. Potluri, Prolonged length of hospital stay in Far-East Asian and Afro-Caribbean patients with cardiomyopathy, Int. J. Cardiol. 176 (1) (Sep 2014) 230–231. [20] R. Potluri, M. Wasim, B. Markandey, A. Kapour, N. Khouw, P. Carter, H. Uppal, S. Chandran, Length of hospital stay is shorter in South Asian patients with ischaemic stroke, Int. J. Cardiol. 187 (6th May 2015) 190–191.
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R.S. Gorantla et al. / International Journal of Cardiology 187 (2015) 542–544
[21] L. Yssennagger, N.D. Gollop, R.S. Gorantla, M. Nimmagadda, S. Potluri, H. Uppal, S. Chandran, R. Potluri, Increasing burden of psychiatric comorbidities amongst patients with Ischaemic Heart Disease, Int. J. Cardiol. 186 (1st may 2015) 200–201. [22] H. Uppal, S. Chandran, R. Potluri, Risk factors for mortality in Down's syndrome, J. Intellect. Disabil. Res. (2015) http://dx.doi.org/10.1111/jir.12196. [23] Carers National Association, ‘You Can take him home now’: Carers' experiences of hospital dischargeAvailable at http://www.carersuk.org/professionals/resources/
research-library/item/517-you-can-take-him-home-now-carers-experiences-ofhospital-dischargeJune 2001 (Last accessed 26 July 2011). [24] Department of Health and Social Services Inspectorate, They look after their own, don't they?Available at http://webarchive.nationalarchives.gov.uk/+/www.dh.gov. uk/en/Publicationsandstatis- tics/Pressreleases/DH_40243321998 (Last accessed 28 July 2011).
