Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Public Health


Epidemiology and Biostatistics

First Advisor

Dr. Steven Browning

Second Advisor

Dr. Anna Kucharska-Newton


Rare diseases of the heart, such as infective endocarditis (IE), myocarditis, and pericarditis, have earned limited attention in cardiovascular research despite their potential for severe morbidity and mortality. Amidst the opioid crisis in the United States, there has been a notable increase in endocarditis hospitalizations among people who inject drugs. Kentucky, at the epicenter of the opioid epidemic, lacks available data on IE hospitalizations. Moreover, the COVID-19 pandemic has introduced unprecedented challenges to healthcare systems, influencing hospitalizations and healthcare utilization patterns. While trends before, during, and after the pandemic have been extensively studied for common cardiovascular diseases, such as heart failure and myocardial infarction, there is a noticeable dearth of data regarding the impact of the pandemic on less common diseases such as endocarditis, myocarditis, and pericarditis. The first two studies of this dissertation analyzed the Kentucky hospital inpatient discharge data from 2008 to 2018 to evaluate trends of IE hospitalizations in Kentucky. County-level hospitalization rates were calculated, and a SaTScan spatiotemporal analysis was performed to identify counties with IE hospitalization clusters. The IE hospitalizations were categorized into drug use-related and non-drug use-related to examine differences in healthcare utilization and clinical outcomes among those groups. The first study showed an increase in hospitalization rates of intravenous drug use (IDU)-associated IE from 1.2 to 27.3 / 100,000 population between 2008 and 2018. It also identified seven statistically significant clusters. The largest cluster was located in the Appalachian region of Eastern Kentucky and occurred between 2015 and 2018 (RR= 2.06, p<0.0001).

The second study reported longer hospital stays and higher hospital charges for IDU-IE compared to non-IDU-IE. When compared to non-IDU-IE, IDU-IE had lower in-hospital mortality; however, an increasing trend for IDU-IE in-hospital mortality was observed from 2008 to 2018, especially among the younger age group (26-45 years).

The third study of this dissertation evaluated the National Inpatient Sample from 2018 to 2020. An interrupted time series analysis was implemented to examine changes in the number of hospitalizations for endocarditis, myocarditis, and pericarditis before and after the national COVID-19-related shutdown in March 2020. The study showed an immediate decrease in monthly admissions for endocarditis and pericarditis soon after the shutdown implementation and a significant increase in myocarditis hospitalizations. Hospital length of stay and in-hospital mortality significantly increased for all three conditions during the pandemic compared to the pre-pandemic period.

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Available for download on Wednesday, March 05, 2025

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