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Original article
Hospital admissions and outcomes for systolic and diastolic heart failure in Spain between 2016 and 2019: A population-based study
Hospitalizaciones y eventos por insuficiencia cardiaca sistólica y diastólica en España entre 2016 y 2019. Un estudio de base poblacional
Juan Luis Bonilla-Palomasa,
Corresponding author
jnlsbnll@hotmail.com

Corresponding author.
, Manuel Anguita-Sánchezb, Cristina Fernández-Pérezc,d, José Luis Bernal-Sobrinoc,e, María Garcíac, Náyade Pradoc, Nicolás Rosilloc, Julián Pérez-Villacastínf, Juan José Gómez-Doblasg, Francisco Javier Elola-Somozac
a Servicio de Cardiología, Hospital San Juan de la Cruz, Úbeda (Jaén), Spain
b Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
c Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
d Departamento de Medicina Preventiva, Área Sanitaria de Santiago de Compostela y Barbanza, Instituto de Investigación de Santiago, Santiago de Compostela, La Coruña, Spain
e Departamento de Control de Gestión, Hospital Universitario 12 de Octubre, Madrid, Spain
f Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain
g Servicio de Cardiología, Hospital Virgen de la Victoria, Málaga, Spain
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            "etiqueta" => "d"
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            "entidad" => "Departamento de Control de Gesti&#243;n&#44; Hospital Universitario 12 de Octubre&#44; Madrid&#44; Spain"
            "etiqueta" => "e"
            "identificador" => "aff0025"
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            "entidad" => "Servicio de Cardiolog&#237;a&#44; Hospital Cl&#237;nico San Carlos&#44; Madrid&#44; Spain"
            "etiqueta" => "f"
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        "titulo" => "Hospitalizaciones y eventos por insuficiencia cardiaca sist&#243;lica y diast&#243;lica en Espa&#241;a entre 2016 y 2019&#46; Un estudio de base poblacional"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagram of exclusions&#46; HF&#58; heart failure&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; is a major public health problem&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Recent registries report that HF with preserved ejection fraction &#40;HFpEF&#41; accounts for almost half of all hospitalisations&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; the major therapeutic advances have occurred in the field of HF with reduced ejection fraction &#40;HFrEF&#41;&#44; but the therapies with prognostic benefits for HFpEF are more limited&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> and maybe for this reason&#44; the multidisciplinary care programmes have taken longer to incorporate patients with HFpEF&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In contrast to other countries&#44; Spain has not witnessed a decrease in hospitalisations for HF in recent decades&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However&#44; Spain lacks population-based data on HF hospitalisations according to type&#44; which is certainly essential as a starting point to determine how to distribute the resources allocated to this disease and to design strategies to improve care and health outcomes&#46; We have therefore developed a nationwide population-based study in which we have analysed HF hospitalisations distinguishing the 2 types and their differences in in-hospital mortality&#44; hospital stay&#44; and 30-day readmissions due to cardiovascular causes between 2016 and 2019&#46; Since our analysis is based on the International Classification of Diseases &#40;ICD&#41;&#44; we used the terms diastolic HF to refer to HFpEF and systolic HF for HFrEF&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design&#44; data source and study population</span><p id="par0010" class="elsevierStylePara elsevierViewall">Retrospective observational study of patients discharged with the principal diagnosis of HF from acute hospitals of the National Health System&#46; The data source was the minimum basic data set &#40;MBDS&#41; of the Ministry of Health&#44; a mandatory administrative registry that includes information on the demographic characteristics of admitted patients&#44; as well as administrative and clinical variables related to the diagnoses and procedures performed on patients during the hospitalisation episode&#44; coded according to the International Classification of Diseases in its tenth revision &#40;ICD-10&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> All episodes with a principal discharge diagnosis of HF from 1 January 2016 to 31 December 2019 were included&#44; classified as diastolic HF &#40;HFpEF&#41;&#44; systolic HF &#40;HFrEF&#41; or unspecified &#40;<a class="elsevierStyleCrossRef" href="#sec0060">Appendix A</a>&#46; Supplementary data&#44; <a class="elsevierStyleCrossRef" href="#sec0060">Table S1</a>&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">To improve data quality and consistency&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0020" class="elsevierStylePara elsevierViewall">Transfers between acute hospitals were considered as a single episode&#44; with the episode data attributed to the hospital of first admission&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0025" class="elsevierStylePara elsevierViewall">Excluded were episodes in patients under 18 years of age&#44; those discharged home with one day or less of stay&#44; discharges due to transfer to another hospital that could not be identified&#44; voluntary discharges&#44; discharges with other destinations or unknown discharge destination and&#44; finally&#44; episodes in patients with left ventricular assist device implantation or heart transplant procedures in the index episode or in the 12 months prior to the index episode&#46;</p></li></ul></p><p id="par0030" class="elsevierStylePara elsevierViewall">The outcome variables analysed were in-hospital mortality and 30-day readmissions for cardiovascular disease &#40;ICD-10 chapter 9&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the identification of readmissions&#44; we excluded in-hospital deaths in the index episode&#44; index episodes with stays longer than one year&#44; and programmed readmissions&#46; If there were several readmissions only the first readmission in the 30 day period was taken into account&#46; Also excluded were index episodes discharged from the departments of oncology&#44; oncological radiotherapy&#44; psychology&#44; psychiatry&#44; rehabilitation&#44; detoxification&#44; palliative care or long-stay unit&#44; episodes in which the patient received a transplant&#44; patients with a principal diagnosis of chemo- or radiotherapy treatment&#44; rehabilitation&#44; fitting of prostheses and devices&#44; and those classified in major diagnostic categories 21 &#40;injuries&#44; poisonings and toxic effects of drugs&#41;&#44; 22 &#40;burns&#41; and 25 &#40;polytrauma&#41; of the <span class="elsevierStyleItalic">All Patients Refined Diagnosis Related Groups</span> &#40;APR-DRG&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The study was conducted in accordance with the Declaration of Helsinki and was exempt from review by a Research Ethics Committee as it is an epidemiological study with data from identified subjects&#46; The study conforms to the EQUATOR guidelines and specifically to the STROBE guidelines for observational studies&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall">Continuous variables are expressed as mean &#40;standard deviation&#41; and categorical variables as numbers and percentages&#46; To compare continuous variables we used Student&#39;s t-test&#44; for 2 factors&#44; or analysis of variance &#40;ANOVA&#41; with Bonferroni correction&#44; for 3 or more factors&#44; and the &#967;<span class="elsevierStyleSup">2</span> test or Fisher&#39;s exact statistic for categorical variables&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We calculated the in-hospital risk-standardised mortality rate and the 30-day readmission risk-standardised rate&#44; defined as the ratios of the predicted outcome &#40;which considers the performance of the individual hospital where the patient is treated&#41; to the expected outcome &#40;which considers a standard performance according to the mean of all hospitals&#41; multiplied by the study population raw mortality&#47;admission rate&#46; For the calculation of both ratios&#44; multilevel logistic regression risk adjustment models were applied&#44; based on the Medicare and Medicaid Services &#40;CMS&#41; methodology&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> The independent variables considered were those included in the HF mortality and 30-day readmission models&#44; adapting the CMS models to the MBDS structure&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> after grouping secondary diagnoses according to the clinical condition &#40;CC&#41; categories developed by Pope et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and updated annually by the Agency for Healthcare Research and Quality&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Backward elimination was used to select the variables included in the adjustment models&#46; The significance levels for selection and elimination of risk factors were p &#60; 0&#46;05 and p &#62; 0&#46;10&#44; respectively&#46; Calibration of the models was assessed by calculating the risk deciles of observed and expected hospital mortality obtained by the multilevel logistic model&#46; To evaluate goodness-of-fit&#44; a significant decrease in the likelihood-ratio statistical test was compared to the null model&#46; Discrimination was tested using the calculation of receiver operating characteristic curves and their corresponding area under the curve &#40;AUROC&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Taking into account the right-skewed nature of the distribution&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> a Poisson regression model was used to model the length of stay&#44; with risk factors taken as patient age&#44; sex&#44; Charlson index by comorbidity levels<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and the severity level of the APR-DRG episode&#46; The expected mean length of stay was calculated from the individual predictions resulting from the fitting model&#46; The length of stay risk-standardised rate was calculated as the ratio of the observed average to the expected length of stay&#46; Incidence rate ratios &#40;IRR&#41; and their 95&#37; confidence interval were calculated in the model&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">All statistical tests were bilateral&#44; and differences found were considered significant at p &#60; 0&#46;05&#46; Statistical analyses were performed with STATA&#174; v&#46;17 and SPSS&#174; v&#46;21&#46;0&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">Of the 495&#44;151 episodes identified with the principal diagnosis of HF during the study period&#44; only 203&#44;321 &#40;41&#46;1&#37;&#41; specified the type of HF&#46; After applying the exclusion criteria &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; 190&#44;200 episodes were selected as the study population&#46; The mean age was 80&#46;7 &#177; 10&#46;2 years&#44; 103&#44;385 &#40;54&#46;4&#37;&#41; episodes were female and 163&#44;727 &#40;86&#46;1&#37;&#41; were classified as diastolic HF&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">As a sensitivity analysis&#44; the profile of unspecified HF episodes &#40;269&#44;423 episodes&#44; after applying the exclusion criteria&#41;&#44; i&#46;e&#46; where the HF type could not be identified&#44; was compared with that of the study population&#46; The two populations were markedly similar &#40;<a class="elsevierStyleCrossRef" href="#sec0060">Appendix A</a>&#46; Supplementary data&#44; <a class="elsevierStyleCrossRef" href="#sec0060">Table S2</a>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Diastolic HF episodes were characterised by older age&#44; a higher percentage of women&#44; diabetes&#44; dementia and renal failure compared to those of systolic HF &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In contrast&#44; the latter had a higher percentage of hypertension&#44; cardiogenic shock&#44; comorbidities related to ischaemic heart disease&#44; and coronary revascularisation procedures &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">No statistically significant differences were found in the raw in-hospital mortality rate between the two groups &#40;10&#46;2&#37; systolic HF vs&#46; 10&#46;6&#37; diastolic HF&#59; p &#61; 0&#46;062&#41;&#46; The adjustment model for in-hospital mortality showed acceptable discrimination &#40;AUROC&#58; 0&#46;73&#41; and good calibration &#40;<a class="elsevierStyleCrossRef" href="#sec0060">Appendix A</a>&#46; Supplementary data&#44; <a class="elsevierStyleCrossRef" href="#sec0060">figure S1</a>&#41;&#46; Stroke&#44; pneumonia on admission and cancer were prominent risk factors for in-hospital mortality&#44; with the presence of cardiogenic shock being the most relevant risk factor &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The risk factors of the multilevel logistic regression model for in-hospital mortality for unspecified HF episodes were remarkably similar to those of the study population &#40;<a class="elsevierStyleCrossRef" href="#sec0060">Appendix A</a>&#46; Supplementary data&#44; <a class="elsevierStyleCrossRef" href="#sec0060">Table S3</a>&#41;&#46; When HF type was entered into the fitting model&#44; diastolic HF was shown to be a protective factor for in-hospital mortality versus systolic HF &#40;OR&#58; 0&#46;79&#44; 95&#37; CI&#58; 0&#46;75&#8722;0&#46;83&#59; p &#60; 0&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The fitting model for readmission within 30-days due to cardiovascular causes showed low discrimination &#40;AUROC&#58; 0&#46;60&#41; and good calibration &#40;<a class="elsevierStyleCrossRef" href="#sec0060">Appendix A</a>&#46; Supplementary data&#44; <a class="elsevierStyleCrossRef" href="#sec0060">figure S2</a>&#41;&#46; Clinical and demographic variables independently associated with the risk of readmission within 30-days due to cardiovascular causes are shown in <a class="elsevierStyleCrossRef" href="#sec0060">Appendix A</a> &#40;Supplementary data&#44; <a class="elsevierStyleCrossRef" href="#sec0060">Table S4</a>&#41;&#46; When HF type was entered into the fitting model&#44; diastolic HF was shown to be a protective factor for readmission within 30-days due to cardiovascular causes versus systolic HF &#40;OR&#58; 0&#46;93&#44; 95&#37; CI&#58; 0&#46;88&#8722;0&#46;97&#59; p &#61; 0&#46;002&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the adjustment model for length of stay &#40;<a class="elsevierStyleCrossRef" href="#sec0060">Appendix A</a>&#46; Supplementary data&#44; <a class="elsevierStyleCrossRef" href="#sec0060">Table S5</a>&#41;&#44; diastolic HF behaved as a protective factor&#44; i&#46;e&#46;&#44; it was associated with a shorter expected length of stay &#40;IRR&#58; 0&#46;96&#8722;0&#46;98&#59; p &#60; 0&#46;001&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">In this study we analysed episodes of hospitalisation for HF in Spain between 2016 and 2019&#44; differentiating between systolic and diastolic HF&#46; We highlight that the number of unspecified HF episodes is very high&#44; accounting for almost 60&#37; of the total&#46; In the fitting models&#44; diastolic HF&#44; the predominant type in the study population&#44; shows a lower risk of in-hospital mortality and readmission within 30-days due to cardiovascular causes and a shorter mean length of stay than systolic HF&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Although HFpEF has been a recognised entity since the 1980s&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> different definitions have been used over the last decades&#46; It is probably within the last 10 years that most progress has been made in the pathophysiological understanding of the syndrome&#44; in uniform terminology and&#44; with it&#44; in the classification of the types of HF&#44; although the debate is still very much alive&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> This lack of uniformity in the classification of HF is inevitably transmitted to administrative records and in some way favours or justifies poor coding of data&#44; without ruling out the possibility that inaccurate discharge reports may also be contributed to this&#46; As concepts and classifications have become more consistent and uniform&#44; coding has improved to the point that&#44; for example&#44; in the USA&#44; population-based studies show how&#44; in one decade&#44; unspecified HF has gone from exceeding half of the episodes to being residual&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The Spanish MBDS has not accurately classified episodes of heart failure as HFpEF or HFrEF &#40;diastolic or systolic&#44; in the terminology used in this study&#41;&#44; so this distinction has not been considered in previous population-based studies&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The same has occurred in other developed countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#8211;22</span></a> The implementation of ICD 10 from 2016 onwards has introduced improvements in administrative coding and&#44; therefore&#44; in the distinction of the pathophysiological type&#44; but even in this latest revision&#44; there are still concepts which are at odds with those used in daily clinical practice&#44; since&#44; as is known&#44; scientific societies currently classify HF into three types&#58; HFrEF &#40;EF &#8804; 40&#37;&#41;&#44; HFpEF &#40;EF &#8805; 50&#37;&#41; and slightly reduced EF &#40;EF&#58; 41&#8211;49 &#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In our study we have taken 2016 as the baseline year&#44; and it is not encouraging to find that in more than 60&#37; of the episodes the HF type is not specified&#46; This mismatch between clinical and administrative reporting is undoubtedly one of the most salient findings of our study&#46; Coding needs to be improved in order to improve understanding of the epidemiological reality of HF and the analysis of health outcomes&#46; During hospitalisation for HF&#44; the following aspects are essential to highlight&#44; as they condition patient management&#58; whether the HF is <span class="elsevierStyleItalic">de novo</span> or chronic decompensated&#59; whether it is with pEF&#44; rEF or slightly reduced&#44; and the aetiology&#46; In this sense&#44; the Spanish Society of Cardiology&#44; fostering coordinated care for HF&#44; has also insisted on this need&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Previous registries of acute HF have shown that patients hospitalised for diastolic HF are equal or greater in number to those hospitalised for systolic HF&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> especially in the older population &#40;65&#37; of cases in those over 75 years of age<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#41;&#46; However&#44; there are hardly any population-based studies that analyse HF hospitalisations according to HF type&#44; especially in Europe and Spain&#44; where such an analysis is being carried out for the first time&#46; According to our data&#44; most HF hospitalisations in Spain should be attributed to diastolic HF&#46; Population-based studies in the USA conducted in different periods from 2003 to 2018&#44; however&#44; show that diastolic HF&#44; although gaining epidemiological weight&#44; does not exceed 40&#37; of HF hospitalisations&#44; so that systolic HF continues to account for the majority&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;25&#8211;27</span></a> This difference could be explained by the older age of our study population&#44; taking into account that the older the age&#44; the higher the percentage of patients with diastolic HF&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> although this is probably insufficient to explain such a notable difference&#46; The percentage of unspecified HF is very high and this could be a limitation&#46; Even so&#44; to check that we have not introduced large biases in the selection of the study population&#44; we compared it with the population of unspecified HF episodes&#44; without finding significant differences&#46; Furthermore&#44; it is striking that the variables related to in-hospital mortality in the unspecified HF population are practically the same as those in the study population&#46; In other words&#44; the two populations can not be very different&#46; Another very interesting issue is that the defining characteristics of the diastolic HF population in our study&#44; as opposed to systolic HF&#44; are found in other population-based studies&#58; older age&#44; higher percentage of women&#44; more obesity&#44; more DM&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;25&#8211;27</span></a> They are even comparable with the characteristics of patients with HFpEF in acute HF registries&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Therefore&#44; and beyond the figures&#44; it does not seem questionable that in our country episodes of hospitalisation for diastolic HF are in the majority&#46; Actions aimed at improving health outcomes in HF should reflect this reality and allocate resources to the older population and to diastolic HF&#46; In Spain&#44; different healthcare initiatives have already demonstrated clinical benefits in elderly multi-pathological patients&#44; where diastolic HF is predominant&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;28</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In-hospital mortality depends on the care model and the characteristics of the population studied&#46; In our study&#44; the raw in-hospital mortality rate was lower than that observed in Spain in the previous decade &#40;12&#46;3&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> but it is still high &#40;over 10&#37;&#41; and notably higher than that reported in other registries and population-based studies&#44; where it is around 3&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;25&#8211;27</span></a> Also as in previous studies&#44; stroke&#44; pneumonia&#44; cancer and especially cardiogenic shock remain prominent risk factors for in-hospital mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In this respect&#44; diastolic HF becomes a protective factor compared to systolic HF&#46; Other population studies and registries have also observed lower in-hospital mortality in diastolic HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;19&#44;25&#8211;27</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Diastolic HF also behaved as a protective factor for readmission within 30-days due to cardiovascular causes and was associated with a shorter average length of stay than systolic HF&#44; in line with other population-based studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;26</span></a></p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Limitations</span><p id="par0125" class="elsevierStylePara elsevierViewall">This is a retrospective study based on data from the MBDS and therefore has the limitations of studies using information from a clinical and administrative database&#46; The quality and completeness of the information in the medical records and discharge reports&#44; as well as the coding process&#44; could influence the results&#46; However&#44; the use of administrative information has proven to be valid for estimating health service outcomes compared to medical records&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In contrast to the methodology used by the CMS&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> readmissions for any cause were not analysed&#44; because the Ministry of Health only provides data on discharges due to cardiac diseases&#46; In addition&#44; information related to patients who died out of hospital could not be obtained&#46; However&#44; our method was similar to previously validated models in terms of its predictive ability&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">An important limitation is the large number of unspecified HF episodes&#46; However&#44; we have already indicated that in order to check that we have not introduced large biases in the selection of the study population&#44; we have compared it with the population of unspecified HF episodes&#44; without finding significant differences&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Finally&#44; the limitations of imprecise coding due to changes in terminology over the last decades&#44; in particular in the field of HF&#44; and the difficulties in adapting the terms diastolic and systolic HF to current cardiology<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> have to be taken into account&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">In Spain&#44; between 2016 and 2019&#44; HF hospitalisation episodes were mostly due to diastolic HF&#46; Actions to improve health outcomes in HF must take this epidemiological reality into account&#46; Episodes of diastolic HF were characterised by old age&#44; a higher percentage of women&#44; diabetes&#44; dementia and renal failure&#44; compared to those of systolic HF&#46; According to risk adjustment models&#44; when compared to systolic HF&#44; diastolic HF behaved as a protective factor for in-hospital mortality and readmission within 30-days due to cardiovascular causes and was associated with a shorter hospital stay&#46; Finally&#44; measures to improve the characterisation and typification of HF episodes in the coding of discharge reports are a priority&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical responsibilities</span><p id="par0150" class="elsevierStylePara elsevierViewall">This study was exempt from review by a Research Ethics Committee and from obtaining informed consent as it was an epidemiological study with identified data&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have not received any funding for this work&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "titulo" => "Conclusions"
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        1 => array:2 [
          "identificador" => "xpalclavsec1788382"
          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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            0 => array:2 [
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              "titulo" => "Antecedentes y objetivos"
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              "titulo" => "M&#233;todos"
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              "titulo" => "Resultados"
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              "titulo" => "Conclusiones"
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          "titulo" => "Palabras clave"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:3 [
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          "titulo" => "Methods"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Study design&#44; data source and study population"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Statistical analysis"
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              "identificador" => "sec0035"
              "titulo" => "Limitations"
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          "titulo" => "Conclusions"
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        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Ethical responsibilities"
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          "identificador" => "sec0050"
          "titulo" => "Funding"
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        11 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflict of interest"
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        12 => array:1 [
          "titulo" => "References"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2023-06-08"
    "fechaAceptado" => "2023-10-07"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1788382"
          "palabras" => array:6 [
            0 => "Heart failure"
            1 => "Admission"
            2 => "Systolic"
            3 => "Diastolic"
            4 => "In-hospital mortality"
            5 => "Readmission"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1788383"
          "palabras" => array:6 [
            0 => "Insuficiencia cardiaca"
            1 => "Hospitalizaci&#243;n"
            2 => "Sist&#243;lica"
            3 => "Diast&#243;lica"
            4 => "Mortalidad intrahospitalaria"
            5 => "Reingreso"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and purpose</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">In Spain there is a lack of population data that specifically compare hospitalization for systolic and diastolic heart failure &#40;HF&#41;&#46; We assessed clinical characteristics&#44; in-hospital mortality and 30-day cardiovascular readmission rates differentiating by HF type&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">We conducted a retrospective observational study of patients discharged with the principal diagnosis of HF from The National Health System&#8217; acute hospital during 2016&#8211;2019&#44; distinguishing between systolic and diastolic HF&#46; The source of the data was the Minimum Basic Data Set&#46; The risk-standardized in-hospital mortality ratio and risk-standardized 30-day cardiovascular readmission ratio were calculated using multilevel risk adjustment models&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">190&#44;200 episodes of HF were selected&#46; Of these&#44; 163&#44;727 &#40;86&#46;1&#37;&#41; were classified as diastolic HF and were characterized by older age&#44; higher proportion of women&#44; diabetes mellitus&#44; dementia and renal failure than those with systolic HF&#46; In the multilevel risk adjustment models&#44; diastolic HF was a protective factor for both in-hospital mortality &#40;Odds ratio-OR-&#58; 0&#46;79&#59; 95&#37; confidence interval &#91;CI&#93;&#44; 0&#46;75&#8722;0&#46;83&#59; p &#60; 0&#46;001&#41; and 30-day cardiovascular readmission versus systolic HF &#40;OR&#58; 0&#46;93&#59; 95&#37;CI&#58; 0&#46;88&#8722;0&#46;97&#59; p &#61; 0&#46;002&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">In Spain&#44; between 2016 and 2019&#44; hospitalization episodes for HF were mostly due to diastolic HF&#46; According to the multilevel risk adjustment models&#44; diastolic HF compared to systolic HF was a protective factor for both in-hospital mortality and 30-day cardiovascular readmission&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and purpose"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">En Espa&#241;a carecemos de datos poblacionales de hospitalizaciones por insuficiencia cardiaca &#40;IC&#41; seg&#250;n sea sist&#243;lica o diast&#243;lica&#46; Analizamos las diferencias cl&#237;nicas&#44; en mortalidad intrahospitalaria y reingresos de causa cardiovascular a los 30 d&#237;as entre ambos tipos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo de pacientes dados de alta con el diagn&#243;stico principal de IC de los hospitales del Sistema Nacional de Salud entre 2016 y 2019&#44; distinguiendo entre IC sist&#243;lica y diast&#243;lica&#46; La fuente de datos fue el Conjunto M&#237;nimo B&#225;sico de Datos del Ministerio de Sanidad&#46; Se calcularon las razones de mortalidad intrahospitalaria y de reingreso a los 30 d&#237;as estandarizadas por riesgo usando sendos modelos de regresi&#243;n log&#237;stica multinivel de ajuste de riesgo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se seleccionaron 190&#46;200 episodios de IC&#46; De ellos&#44; 163&#46;727 &#40;86&#44;1&#37;&#41; fueron por IC diast&#243;lica y se caracterizaron por presentar mayor edad&#44; mayor proporci&#243;n de mujeres&#44; de diabetes y de insuficiencia renal que los de IC sist&#243;lica&#46; Seg&#250;n los modelos de ajuste de riesgo la IC diast&#243;lica&#44; frente a la sist&#243;lica&#44; se comport&#243; como un factor protector de mortalidad intrahospitalaria &#40;Odds ratio &#91;OR&#93;&#58; 0&#44;79&#59; intervalo de confianza &#91;IC&#93;95&#37; 0&#44;75&#8722;0&#44;83&#59; p&#60;0&#44;001&#41; y de reingreso de causa cardiovascular a los 30 d&#237;as &#40;OR&#58; 0&#44;93&#59; IC95&#37;&#58; 0&#44;88&#8722;0&#44;97&#59; p &#61; 0&#44;002&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">En Espa&#241;a&#44; entre 2016 y 2019&#44; los episodios de hospitalizaci&#243;n por IC fueron mayoritariamente por IC diast&#243;lica&#46; Seg&#250;n los modelos de ajuste de riesgo la IC diast&#243;lica&#44; con respecto a la sist&#243;lica&#44; fue un factor protector de mortalidad intrahospitalaria y de reingreso de causa cardiovascular a los 30 d&#237;as&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Antecedentes y objetivos"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
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    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0170" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0065"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 3009
            "Ancho" => 3161
            "Tamanyo" => 385519
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0080"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagram of exclusions&#46; HF&#58; heart failure&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0085"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CC&#58; condition categories<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#59; HF&#58; heart failure&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total CI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Systolic HF&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diastolic HF&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Value of p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">190&#44;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#44;473&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">163&#44;727&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&#44; mean &#40;standard deviation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#46;7 &#40;10&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#46;8 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#46;5 &#40;9&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Women&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">History of coronary artery bypass surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">483&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">History of percutaneous coronary angioplasty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">13&#46; 43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metastatic cancer&#44; acute leukaemia and other serious cancers &#40;CC 8&#8722;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitus &#40;DM&#41; or DM with complications other than proliferative retinopathy &#40;CC 17&#8722;19&#44; 123&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Protein-calorie malnutrition &#40;CC 21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;332&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic liver disease &#40;CC 27&#8722;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dementia or other brain disorders &#40;CC 51&#8722;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Major psychiatric disorders &#40;CC 57&#8722;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemiplegia&#44; paraplegia&#44; paralysis&#44; functional disability &#40;CC 70&#8722;74&#44; 103&#8722;104&#44; 189&#8722;190&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;912&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiogenic shock &#40;R57&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiorespiratory failure except cardiogenic shock &#40;CC 84 except R57&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute myocardial infarction &#40;CC 86&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unstable angina and other acute ischaemic heart diseases &#40;CC 87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coronary atherosclerosis or angina &#40;CC 88&#8722;89&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Valvulopathies and rheumatic heart disease &#40;CC 91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High blood pressure &#40;CC 95&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stroke &#40;CC 99&#8722;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;575&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular disease and complications &#40;CC 106&#8722;108&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic obstructive pulmonary disease &#40;CC 111&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;752&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pneumonia &#40;CC 114&#8722;116&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kidney failure &#40;CC 135&#8722;140&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Trauma&#59; other injuries &#40;CC 166&#8722;168&#44; 170&#8722;174&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CC&#58; condition categories<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#59; CI&#58; confidence interval&#59; OR&#58; odds ratio&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P &#62; z&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#91;0&#46;4&#8722;5&#93; 95&#37; CI</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metastatic cancer&#46; acute leukaemia and other serious cancers &#40;CC 8&#8722;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Protein-calorie malnutrition &#40;CC 21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic liver disease &#40;CC 27&#8722;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dementia or other brain disorders &#40;CC 51&#8722;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemiplegia&#46; paraplegia&#46; paralysis&#46; functional disability &#40;CC 70&#8722;74&#46; 103&#8722;104&#46; 189&#8722;190&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiogenic shock &#40;R57&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiorespiratory failure except cardiogenic shock &#40;CC 84 except R57&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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Original language: English
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