Trends in Drug Use-Associated Infective Endocarditis and Heart Valve Surgery, 2007 to 2017: A Study of Statewide Discharge Data

Ann Intern Med. 2019 Jan 1;170(1):31-40. doi: 10.7326/M18-2124. Epub 2018 Dec 4.


Background: Drug use-associated infective endocarditis (DUA-IE) is increasing as a result of the opioid epidemic. Infective endocarditis may require valve surgery, but surgical treatment of DUA-IE has invoked controversy, and the extent of its use is unknown.

Objective: To examine hospitalization trends for DUA-IE, the proportion of hospitalizations with surgery, patient characteristics, length of stay, and charges.

Design: 10-year analysis of a statewide hospital discharge database.

Setting: North Carolina hospitals, 2007 to 2017.

Patients: All patients aged 18 years or older hospitalized for IE.

Measurements: Annual trends in all IE admissions and in IE hospitalizations with valve surgery, stratified by patients' drug use status. Characteristics of DUA-IE surgical hospitalizations, including patient demographic characteristics, length of stay, disposition, and charges.

Results: Of 22 825 IE hospitalizations, 2602 (11%) were for DUA-IE. Valve surgery was performed in 1655 IE hospitalizations (7%), including 285 (17%) for DUA-IE. Annual DUA-IE hospitalizations increased from 0.92 to 10.95 and DUA-IE hospitalizations with surgery from 0.10 to 1.38 per 100 000 persons. In the final year, 42% of IE valve surgeries were performed in patients with DUA-IE. Compared with other surgical patients with IE, those with DUA-IE were younger (median age, 33 vs. 56 years), were more commonly female (47% vs. 33%) and white (89% vs. 63%), and were primarily insured by Medicaid (38%) or uninsured (35%). Hospital stays for DUA-IE were longer (median, 27 vs. 17 days), with higher median charges ($250 994 vs. $198 764). Charges for 282 DUA-IE hospitalizations exceeded $78 million.

Limitation: Reliance on administrative data and billing codes.

Conclusion: DUA-IE hospitalizations and valve surgeries increased more than 12-fold, and nearly half of all IE valve surgeries were performed in patients with DUA-IE. The swell of patients with DUA-IE is reshaping the scope, type, and financing of health care resources needed to effectively treat IE.

Primary funding source: National Institutes of Health.

MeSH terms

  • Adult
  • Aged
  • Endocarditis / complications*
  • Endocarditis / surgery*
  • Female
  • Heart Valve Diseases / complications
  • Heart Valve Diseases / surgery
  • Heart Valve Prosthesis Implantation / economics
  • Heart Valve Prosthesis Implantation / statistics & numerical data*
  • Heart Valves / surgery*
  • Hospital Charges
  • Hospitalization / economics
  • Hospitalization / statistics & numerical data*
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • North Carolina / epidemiology
  • Retrospective Studies
  • Risk Factors
  • Substance-Related Disorders / complications*