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Oami T, Imaeda T, Nakada TA, Aizimu T, Takahashi N, Abe T, Yamao Y, Nakagawa S, Ogura H, Shime N, Umemura Y, Matsushima A, Fushimi K. Association of Intensive Care Unit Case Volume With Mortality and Cost in Sepsis Based on a Japanese Nationwide Medical Claims Database Study. Cureus 2024; 16:e65697. [PMID: 39211697 PMCID: PMC11358338 DOI: 10.7759/cureus.65697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
Background The impact of intensive care unit (ICU) case volume on the mortality and medical costs of sepsis has not been fully elucidated. We hypothesized that ICU case volume is associated with mortality and medical costs in patients with sepsis in Japan. Methodology This retrospective nationwide study used the Japanese administrative data from 2010 to 2017. The ICU volume categorization into quartiles was performed according to the annual number of sepsis cases. The primary and secondary outcomes were in-hospital mortality and medical costs, respectively. A mixed-effects logistic model with a two-level hierarchical structure was used to adjust for baseline imbalances. Fractional polynomials were investigated to determine the significance of the association between hospital volume and clinical outcomes. Subgroup and sensitivity analyses were performed for the primary outcome. Results Among 317,365 sepsis patients from 532 hospitals, the crude in-hospital mortality was 26.0% and 21.4% in the lowest and highest quartile of sepsis volume, respectively. After adjustment for confounding factors, in-hospital mortality in the highest quartile was significantly lower than that of the lowest quartile (odds ratio = 0.829; 95% confidence interval = 0.794-0.865; p < 0.001). Investigations with fractional polynomials revealed that sepsis caseload was significantly associated with in-hospital mortality. The highest quartile had higher daily medical costs per person compared to the lowest quartile. Subgroup analyses showed that high-volume ICUs with patients undergoing mechanical ventilation, vasopressor therapy, and renal replacement therapy had a significantly low in-hospital mortality. The sensitivity analysis, excluding patients who were transferred to other hospitals, demonstrated a result consistent with that of the primary test. Conclusions This nationwide study using the medical claims database suggested that a higher ICU case volume is associated with lower in-hospital mortality and higher daily medical costs per person in patients with sepsis.
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Affiliation(s)
- Takehiko Oami
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Taro Imaeda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Tuerxun Aizimu
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Toshikazu Abe
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, JPN
| | - Yasuo Yamao
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, JPN
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, JPN
| | - Hiroshi Ogura
- Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, JPN
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, JPN
| | - Yutaka Umemura
- Emergency Medicine, Osaka General Medical Center, Osaka, JPN
| | - Asako Matsushima
- Department of Emergency, Nagoya City University East Medical Center, Nagoya, JPN
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, JPN
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Liu J, Hui Q, Lu X, Li W, Li N, Chen Y, Zhang Q. Predictive value of laboratory indicators for in-hospital death in children with community-onset sepsis: a prospective observational study of 266 patients. BMJ Paediatr Open 2024; 8:e002329. [PMID: 38754894 PMCID: PMC11097807 DOI: 10.1136/bmjpo-2023-002329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/05/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES This study aimed to identify predictors of sepsis-associated in-hospital mortality from readily available laboratory biomarkers at onset of illness that include haematological, coagulation, liver and kidney function, blood lipid, cardiac enzymes and arterial blood gas. METHODS Children with sepsis were enrolled consecutively in a prospective observational study involving paediatric intensive care units (PICUs) of two hospitals in Beijing, between November 2016 and January 2020. The data on demographics, laboratory examinations during the first 24 hours after PICU admission, complications and outcomes were collected. We screened baseline laboratory indicators using the Least Absolute Shrinkage and Selection Operator (LASSO) analysis, then we constructed a mortality risk model using Cox proportional hazards regression analysis. The ability of risk factors to predict in-hospital mortality was evaluated by receiver operating characteristic (ROC) curves. RESULTS A total of 266 subjects were enrolled including 44 (16.5%) deaths and 222 (83.5%) survivors. Those who died showed a shorter length of hospitalisation, and a higher proportion of mechanical ventilation, complications and organ failure (p<0.05). LASSO analysis identified 13 clinical parameters related to prognosis, which were included in the final Cox model. An elevated triglyceride (TG) remained the most significant risk factor of death (HR=1.469, 95% CI: 1.010 to 2.136, p=0.044), followed by base excess (BE) (HR=1.131, 95% CI: 1.046 to 1.223, p=0.002) and pH (HR=0.95, 95% CI: 0.93 to 0.97, p<0.001). The results of the ROC curve showed that combined diagnosis of the three indicators-TG+BE+pH-has the best area under the curve (AUC) (AUC=0.77, 95% CI: 0.69 to 0.85, p<0.001), with a 68% sensitivity and 80% specificity. CONCLUSION Laboratory factors of TG, BE and pH during the first 24 hours after intensive care unit admission are associated with in-hospital mortality in PICU patients with sepsis. The combination of the three indices has high diagnostic value.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
- Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Qin Hui
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
| | - Xiuxiu Lu
- Department of Intensive Care Unit, Capital Institute of Pediatrics, Beijing, China
| | - Wei Li
- Department of Intensive Care Unit, Capital Institute of Pediatrics, Beijing, China
| | - Ning Li
- Department of Intensive Care Unit, Capital Institute of Pediatrics, Beijing, China
| | - Yuanmei Chen
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
| | - Qi Zhang
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
- Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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Edelstein J, Li CY, Meythaler J, Weaver JA, Graham JE. Inpatient Rehabilitation Facility Ownership Type Yields Mixed Performances on Quality Measures. Arch Phys Med Rehabil 2024; 105:443-451. [PMID: 37907161 PMCID: PMC11006015 DOI: 10.1016/j.apmr.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To evaluate the effects of inpatient rehabilitation facility (IRF) ownership type on IRF-Quality Reporting Program (IRF-QRP) measures. DESIGN Cross-sectional, observational design. SETTING We used 2 Centers for Medicare and Medicare publicly-available, facility-level data sources: (1) IRF compare files and (2) IRF rate setting files - final rule. Data from 2021 were included. PARTICIPANTS The study sample included 1092 IRFs (N=1092). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We estimated the effects of IRF ownership type, defined as for-profit and nonprofit, on 15 IRF-QRP measures using general linear models. Models were adjusted for the following facility-level characteristics: (1) Centers for Medicare and Medicaid census divisions; (2) number of discharges; (3) teaching status; (4) freestanding vs hospital unit; and (5) estimated average weight per discharge. RESULTS Ownership type was significantly associated with 9 out of the fifteen IRF-QRP measures. Nonprofit IRFs performed better with having lower readmissions rates within stay and 30-day post discharge. For-profit IRFs performed better for all the functional measures and with higher rates of returning to home and the community. Lastly, for-profit IRFs spent more per Medicare beneficiary. CONCLUSIONS Ideally, IRF performance would not vary based on ownership type. However, we found that ownership type is associated with IRF-QRP performance scores. We suggest that future studies investigate how ownership type affects patient-level outcomes and the longitudinal effect of ownership type on IRF-QRP measures.
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Affiliation(s)
- Jessica Edelstein
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO.
| | - Chih-Ying Li
- Department of Occupational Therapy, School of Health Professions, University of Texas Medical Branch, Galveston, TX
| | - Jay Meythaler
- Department of Physical Medicine and Rehabilitation, Wayne State University, Detroit, MI
| | - Jennifer A Weaver
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO
| | - James E Graham
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO
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Sun HJ, Zheng GL, Wang ZC, Liu Y, Bao N, Xiao PX, Lu QB, Zhang JR. Chicoric acid ameliorates sepsis-induced cardiomyopathy via regulating macrophage metabolism reprogramming. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 123:155175. [PMID: 37951150 DOI: 10.1016/j.phymed.2023.155175] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/14/2023] [Accepted: 10/29/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Sepsis-related cardiac dysfunction is believed to be a primary cause of high morbidity and mortality. Metabolic reprogramming is closely linked to NLRP3 inflammasome activation and dysregulated glycolysis in activated macrophages, leading to inflammatory responses in septic cardiomyopathy. Succinate dehydrogenase (SDH) and succinate play critical roles in the progression of metabolic reprogramming in macrophages. Inhibition of SDH may be postulated as an effective strategy to attenuate macrophage activation and sepsis-induced cardiac injury. PURPOSE This investigation was designed to examine the role of potential compounds that target SDH in septic cardiomyopathy and the underlying mechanisms involved. METHODS/RESULTS From a small molecule pool containing about 179 phenolic compounds, we found that chicoric acid (CA) had the strongest ability to inhibit SDH activity in macrophages. Lipopolysaccharide (LPS) exposure stimulated SDH activity, succinate accumulation and superoxide anion production, promoted mitochondrial dysfunction, and induced the expression of hypoxia-inducible factor-1α (HIF-1α) in macrophages, while CA ameliorated these changes. CA pretreatment reduced glycolysis by elevating the NAD+/NADH ratio in activated macrophages. In addition, CA promoted the dissociation of K(lysine) acetyltransferase 2A (KAT2A) from α-tubulin, and thus reducing α-tubulin acetylation, a critical event in the assembly and activation of NLRP3 inflammasome. Overexpression of KAT2A neutralized the effects of CA, indicating that CA inactivated NLRP3 inflammasome in a specific manner that depended on KAT2A inhibition. Importantly, CA protected the heart against endotoxin insult and improved sepsis-induced cardiac mitochondrial structure and function disruption. Collectively, CA downregulated HIF-1α expression via SDH inactivation and glycolysis downregulation in macrophages, leading to NLRP3 inflammasome inactivation and the improvement of sepsis-induced myocardial injury. CONCLUSION These results highlight the therapeutic role of CA in the resolution of sepsis-induced cardiac inflammation.
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Affiliation(s)
- Hai-Jian Sun
- Department of Basic Medicine, Wuxi School of Medicine, Jiangnan University, Wuxi 214122, China; State Key Laboratory of Natural Medicines, China Pharmaceutical University, No. 24 Tongjia Lane, Nanjing 210009, China
| | - Guan-Li Zheng
- Department of Anesthesiology, Affiliated Hospital of Jiangnan University, Jiangnan University, Wuxi, China
| | - Zi-Chao Wang
- State Key Laboratory of Natural Medicines, China Pharmaceutical University, No. 24 Tongjia Lane, Nanjing 210009, China
| | - Yao Liu
- Department of Cardiac Ultrasound, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210000, China
| | - Neng Bao
- Department of Nephrology, Affiliated Hospital of Jiangnan University, Jiangnan University, Wuxi 214125, China
| | - Ping-Xi Xiao
- Department of Cardiology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 210000, China.
| | - Qing-Bo Lu
- Department of Endocrine, Affiliated Hospital of Jiangnan University, Jiangnan University, Wuxi 214125, China.
| | - Ji-Ru Zhang
- Department of Anesthesiology, Affiliated Hospital of Jiangnan University, Jiangnan University, Wuxi, China.
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Ofoma UR, Lanter TJ, Deych E, Kollef M, Wan F, Joynt Maddox KE. Patient and Hospital Characteristics Associated With the Interhospital Transfer of Adult Patients With Sepsis. Crit Care Explor 2023; 5:e1009. [PMID: 38046937 PMCID: PMC10688774 DOI: 10.1097/cce.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
IMPORTANCE The interhospital transfer (IHT) of patients with sepsis to higher-capability hospitals may improve outcomes. Little is known about patient and hospital factors associated with sepsis IHT. OBJECTIVES We evaluated patterns of hospitalization and IHT and determined patient and hospital factors associated with the IHT of adult patients with sepsis. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS A total of 349,938 adult patients with sepsis at 329 nonfederal hospitals in California, 2018-2019. MAIN OUTCOMES AND MEASURES We evaluated patterns of admission and outward IHT between low sepsis-, intermediate sepsis-, and high sepsis-capability hospitals. We estimated odds of IHT using generalized estimating equations logistic regression with bootstrap stepwise variable selection. RESULTS Among the cohort, 223,202 (66.4%) were initially hospitalized at high-capability hospitals and 10,870 (3.1%) underwent IHT. Nearly all transfers (98.2%) from low-capability hospitals were received at higher-capability hospitals. Younger age (< 65 yr) (adjusted odds ratio [aOR] 1.54; 95% CI, 1.40-1.69) and increasing organ dysfunction (aOR 1.22; 95% CI, 1.19-1.25) were associated with higher IHT odds, as were admission to low-capability (aOR 2.79; 95% CI, 2.33-3.35) or public hospitals (aOR 1.35; 95% CI, 1.09-1.66). Female sex (aOR 0.88; 95% CI, 0.84-0.91), Medicaid insurance (aOR 0.59; 95% CI, 0.53-0.66), home to admitting hospital distance less than or equal to 10 miles (aOR 0.92; 95% CI, 0.87-0.97) and do-not-resuscitate orders (aOR 0.48; 95% CI, 0.45-0.52) were associated with lower IHT odds, as was admission to a teaching hospital (aOR 0.83; 95% CI, 0.72-0.96). CONCLUSIONS AND RELEVANCE Most patients with sepsis are initially hospitalized at high-capability hospitals. The IHT rate for sepsis is low and more likely to originate from low-capability and public hospitals than from high-capability and for-profit hospitals. Transferred patients with sepsis are more likely to be younger, male, sicker, with private medical insurance, and less likely to have care limitation orders. Future studies should evaluate the comparative benefits of IHT from low-capability hospitals.
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Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO
| | - Tierney J Lanter
- Division of Cardiology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - Elena Deych
- Division of Cardiology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Fei Wan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
- Center for Advancing Health Services, Policy and Economics Research, Washington University Institute of Public Health, St. Louis, MO
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Ofoma UR, Deych E, Mohr NM, Walkey A, Kollef M, Wan F, Joynt Maddox KE. The Relationship Between Hospital Capability and Mortality in Sepsis: Development of a Sepsis-Related Hospital Capability Index. Crit Care Med 2023; 51:1479-1491. [PMID: 37338282 PMCID: PMC10615795 DOI: 10.1097/ccm.0000000000005973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Regionalized sepsis care could improve sepsis outcomes by facilitating the interhospital transfer of patients to higher-capability hospitals. There are no measures of sepsis capability to guide the identification of such hospitals, although hospital case volume of sepsis has been used as a proxy. We evaluated the performance of a novel hospital sepsis-related capability (SRC) index as compared with sepsis case volume. DESIGN Principal component analysis (PCA) and retrospective cohort study. SETTING A total of 182 New York (derivation) and 274 Florida and Massachusetts (validation) nonfederal hospitals, 2018. PATIENTS A total of 89,069 and 139,977 adult patients (≥ 18 yr) with sepsis were directly admitted into the derivation and validation cohort hospitals, respectively. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We derived SRC scores by PCA of six hospital resource use characteristics (bed capacity, annual volumes of sepsis, major diagnostic procedures, renal replacement therapy, mechanical ventilation, and major therapeutic procedures) and classified hospitals into capability score tertiles: high, intermediate, and low. High-capability hospitals were mostly urban teaching hospitals. Compared with sepsis volume, the SRC score explained more variation in hospital-level sepsis mortality in the derivation (unadjusted coefficient of determination [ R2 ]: 0.25 vs 0.12, p < 0.001 for both) and validation (0.18 vs 0.05, p < 0.001 for both) cohorts; and demonstrated stronger correlation with outward transfer rates for sepsis in the derivation (Spearman coefficient [ r ]: 0.60 vs 0.50) and validation (0.51 vs 0.45) cohorts. Compared with low-capability hospitals, patients with sepsis directly admitted into high-capability hospitals had a greater number of acute organ dysfunctions, a higher proportion of surgical hospitalizations, and higher adjusted mortality (odds ratio [OR], 1.55; 95% CI, 1.25-1.92). In stratified analysis, worse mortality associated with higher hospital capability was only evident among patients with three or more organ dysfunctions (OR, 1.88 [1.50-2.34]). CONCLUSIONS The SRC score has face validity for capability-based groupings of hospitals. Sepsis care may already be de facto regionalized at high-capability hospitals. Low-capability hospitals may have become more adept at treating less complicated sepsis.
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Affiliation(s)
- Uchenna R. Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis MO, USA
| | - Elena Deych
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis MO, USA
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia, and Epidemiology, University of Iowa Carver College of Medicine, Iowa City IA, USA
| | - Allan Walkey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St. Louis, St. Louis MO, USA
| | - Fei Wan
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis MO, USA
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis MO, USA
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Teixeira RMP, Oliveira JC, de Andrade MAB, Pinheiro FGDMS, Vieira RDCA, Santana-Santos E. Are patient volume and care level in teaching hospitals variables affecting clinical outcomes in adult intensive care units? EINSTEIN-SAO PAULO 2023; 21:eAO0406. [PMID: 37820201 PMCID: PMC10519666 DOI: 10.31744/einstein_journal/2023ao0406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/07/2023] [Indexed: 10/13/2023] Open
Abstract
Teixeira et al. showed that patients admitted to the intensive care unit of a teaching hospital in a non-metropolitan region needed more support, had worse prognostic indices, and had a higher nursing workload in the first 24 hours of admission. In addition, worse outcomes, including mortality, need for dialysis, pressure injury, infection, prolonged mechanical ventilation, and prolonged hospital stay, were observed in the teaching hospital. Worse outcomes were more prevalent in the teaching hospital. Understanding the importance of teaching hospitals to implement well-established care protocols is critical. OBJECTIVE To compare the clinical outcomes of patients admitted to the intensive care unit of teaching (HI) and nonteaching (without an academic affiliation; H2) hospitals. METHODS In this prospective cohort study, adult patients hospitalized between August 2018 and July 2019, with a minimum length of stay of 24 hours in the intensive care unit, were included. Patients with no essential information in their medical records to evaluate the study outcomes were excluded. Resuslts: Overall, 219 patients participated in this study. The clinical and demographic characteristics of patients in H1 and H2 were similar. The most prevalent clinical outcomes were death, need for dialysis, pressure injury, length of hospital stay, mechanical ventilation >48 hours, and infection, all of which were more prevalent in the teaching hospital. CONCLUSION Worse outcomes were more prevalent in the teaching hospital. There was no difference between the institutions concerning the survival rate of patients as a function of length of hospital stay; however, a difference was observed in intensive care unit admissions.
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Affiliation(s)
| | - Jussiely Cunha Oliveira
- Universidade Federal de SergipeSão CristovãoSEBrazil Universidade Federal de Sergipe, São Cristovão, SE, Brazil.
| | | | | | | | - Eduesley Santana-Santos
- Universidade Federal de SergipeSão CristovãoSEBrazil Universidade Federal de Sergipe, São Cristovão, SE, Brazil.
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Zhang X, Li S, Luo H, He S, Yang H, Li L, Tian T, Han Q, Ye J, Huang C, Liu A, Jiang Y. Identification of heptapeptides targeting a lethal bacterial strain in septic mice through an integrative approach. Signal Transduct Target Ther 2022; 7:245. [PMID: 35871689 PMCID: PMC9309159 DOI: 10.1038/s41392-022-01035-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/06/2022] [Accepted: 05/18/2022] [Indexed: 11/11/2022] Open
Abstract
Effectively killing pathogenic bacteria is key for the treatment of sepsis. Although various anti-infective drugs have been used for the treatment of sepsis, the therapeutic effect is largely limited by the lack of a specific bacterium-targeting delivery system. This study aimed to develop antibacterial peptides that specifically target pathogenic bacteria for the treatment of sepsis. The lethal bacterial strain Escherichia coli MSI001 was isolated from mice of a cecal ligation and puncture (CLP) model and was used as a target to screen bacterial binding heptapeptides through an integrative bioinformatics approach based on phage display technology and high-throughput sequencing (HTS). Heptapeptides binding to E. coli MSI001 with high affinity were acquired after normalization by the heptapeptide frequency of the library. A representative heptapeptide VTKLGSL (VTK) was selected for fusion with the antibacterial peptide LL-37 to construct the specific-targeting antibacterial peptide VTK-LL37. We found that, in comparison with LL37, VTK-LL37 showed prominent bacteriostatic activity and an inhibitive effect on biofilm formation in vitro. In vivo experiments demonstrated that VTK-LL37 significantly inhibited bacterial growth, reduced HMGB1 expression, alleviated lesions of vital organs and improved the survival of mice subjected to CLP modeling. Furthermore, membrane DEGP and DEGQ were identified as VTK-binding proteins by proteomic methods. This study provides a novel strategy for targeted pathogen killing, which is helpful for the treatment of sepsis in the era of precise medicine.
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Chan HK, Khose S, Chavez S, Patel B, Wang HE. Updated estimates of sepsis hospitalizations at United States academic medical centers. J Am Coll Emerg Physicians Open 2022; 3:e12782. [PMID: 35859855 PMCID: PMC9288236 DOI: 10.1002/emp2.12782] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/19/2022] [Accepted: 06/01/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Sepsis is a major public health problem. Understanding the epidemiology of sepsis subtypes is important to quantify the magnitude of the problem and identify targets for system wide treatment strategies. We sought to describe the current national epidemiology of community-acquired (CAS), hospital-acquired (HAS) and healthcare-associated sepsis (HCAS) hospitalizations among academic medical centers in the United States using current discharge diagnosis taxonomies. Methods Retrospective analysis of patient discharge data from the Vizient Clinical Data Base/Resource Manager. We identified sepsis hospitalizations using four ICD-10 coding strategies: (1) "Martin" sepsis codes (21 ICD-10 codes), (2) "Angus" sepsis codes (ICD-10 infection + ICD-10 organ dysfunction), (3) Medicare "SEP-1" codes (28 ICD-10 codes), and (4) "explicit sepsis" codes (ICD-10 R65.20 and R65.21). Using present-on-admission flags for each diagnosis, we also distinguished: (1) community-acquired sepsis (CAS), (2) hospital-acquired sepsis (HAS), and (3) healthcare associated sepsis (HCAS). Results Among 22,655,240 hospitalizations, the number and incidence of sepsis hospitalizations were: (1) Martin (n = 1,718,257, 75.8 per 1000 hospitalizations), (2) Angus (n = 2,749,163, 121.3 per 1000), (3) SEP-1 (n = 1,624,909, 71.7 per 1000), and (4) explicit sepsis (n = 655,853, 28.9 per 1000). CAS was the most common sepsis subtype. HAS exhibited higher adjusted mortality than CAS. ICU admission was highest for HAS (Martin, 1.5%; Angus, 1.5%; SEP-1, 1.6%; Explicit, 1.9%). Conclusions These results illustrate the prevalence of sepsis at US academic medical centers using the most current sepsis classification taxonomies and discharge diagnosis codes. These results highlight important considerations when using hospital discharge data to characterize the epidemiology of sepsis.
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Affiliation(s)
- Hei Kit Chan
- Department of Emergency Medicine, Department of BiostatisticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Swapnil Khose
- Department of Epidemiology, Human Genetics & Environmental Sciences, School of Public HealthThe University of Texas Health Science Center at HoustonHoustonTexasUSA
- Department of Emergency Medicine, McGovern Medical SchoolThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Summer Chavez
- Department of Emergency Medicine, Department of BiostatisticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Bela Patel
- Department of Medicine, Division of Critical Care MedicineThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
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10
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van den Berg M, van Beuningen FE, Ter Maaten JC, Bouma HR. Hospital-related costs of sepsis around the world: A systematic review exploring the economic burden of sepsis. J Crit Care 2022; 71:154096. [PMID: 35839604 DOI: 10.1016/j.jcrc.2022.154096] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/29/2022] [Accepted: 06/02/2022] [Indexed: 10/17/2022]
Abstract
AIM The aim of this study was to examine the quality of manuscripts reporting sepsis health care costs and to provide an overview of hospital-related expenditures for sepsis in adult patients around the world. METHODS We systematically searched the PubMed, EMBASE, Cochrane and Google Scholar to identify relevant studies between January 2010 and January 2022. We selected articles that provided costs and cost-effectiveness analyses, defined sepsis and described their cost calculation method. All costs were adjusted to 2020 US dollars. Medians and interquartile ranges (IQRs) for various costs of sepsis were calculated. The quality of economic studies was assessed using the Drummond 10-item checklist. RESULTS Overall, 26 studies met our eligibility criteria. The mean total hospital costs per patient varied largely, between €1101 and €91,951. The median (IQR) of the total sepsis costs per country were €36,191 (€17,158 - €53,349), which equals €50 (€34 - €84) per capita annually. The relative amount of healthcare budget spent on sepsis was 2.65%, which equals 0.33% of the gross national product (GNP). CONCLUSION While general sepsis costs are high, there is considerable variability between countries regarding the costs of sepsis. Further studies examining the impact on sepsis costs, especially on the general ward, can help justify, design and monitor initiatives on prevention, diagnosis, and treatment of this time-critical and potentially preventable disease.
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Affiliation(s)
- M van den Berg
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - F E van Beuningen
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - J C Ter Maaten
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - H R Bouma
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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11
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Naar L, Hechi MWE, Gallastegi AD, Renne BC, Fawley J, Parks JJ, Mendoza AE, Saillant NN, Velmahos GC, Kaafarani HMA, Lee J. Intensive Care Unit Volume of Sepsis Patients Does Not Affect Mortality: Results of a Nationwide Retrospective Analysis. J Intensive Care Med 2022; 37:728-735. [PMID: 34231406 DOI: 10.1177/08850666211024184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is little research evaluating outcomes from sepsis in intensive care units (ICUs) with lower sepsis patient volumes as compared to ICUs with higher sepsis patient volumes. Our objective was to compare the outcomes of septic patients admitted to ICUs with different sepsis patient volumes. MATERIALS AND METHODS We included all patients from the eICU-CRD database admitted for the management of sepsis with blood lactate ≥ 2mmol/L within 24 hours of admission. Our primary outcome was ICU mortality. Secondary outcomes included hospital mortality, 30-day ventilator free days, and initiation of renal replacement therapy (RRT). ICUs were grouped in quartiles based on the number of septic patients treated at each unit. RESULTS 10,716 patients were included in our analysis; 272 (2.5%) in low sepsis volume ICUs, 1,078 (10.1%) in medium-low sepsis volume ICUs, 2,608 (24.3%) in medium-high sepsis volume ICUs, and 6,758 (63.1%) in high sepsis volume ICUs. On multivariable analyses, no significant differences were documented regarding ICU and hospital mortality, and ventilator days in patients treated in lower versus higher sepsis volume ICUs. Patients treated at lower sepsis volume ICUs had lower rates of RRT initiation as compared to high volume units (medium-high vs. high: OR = 0.78, 95%CI = 0.66-0.91, P-value = 0.002 and medium-low vs. high: OR = 0.57, 95%CI = 0.44-0.73, P-value < 0.001). CONCLUSION The previously described volume-outcome association in septic patients was not identified in an intensive care setting.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Majed W El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B Christian Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jarone Lee
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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12
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Wasfie T, Buzadzhi A, Naisan M, Cataline C, Ahmady A, Wong V, Hicken J, Depuydt M, Hella J, Senger B, Barber K. Effect of Implementation of an Early Treatment of Sepsis Protocol on Surgical Outcomes. Am Surg 2022; 88:2227-2229. [PMID: 35476539 DOI: 10.1177/00031348221091971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sepsis outcomes remain high regarding mortality and morbidity, despite efforts to reduce them. We retrospectively evaluated a protocol in the first 6 months of implementation to measure outcomes. Retrospective data collection and analysis was performed of 200 consecutive patients seen in the ED during the first 4 months of 2020 after implementation of the sepsis protocol (group 1) and compared to another 200 consecutive patients during the same time frame in 2019 before the sepsis protocol (group 2). The collected parameters included age, gender, race, length of stay comorbid conditions, mortality, and therapy received. Statistical significance was determined at a p-value ≤.05. Mean age and gender of the groups were similar, 64 vs 66 years for group 1 and 2, respectively. Each group was 45% male. Mean length of stay were 8.9 and 8.6 days in group 1 and 2, respectively. Group 1 had a mortality rate of 13% vs 18% in group 2 (p = .21). Comorbid conditions including cardiovascular disease, diabetes, renal failure, and COPD were analyzed regarding mortality that influenced outcomes using Cox regression analysis. COPD and diabetic patient mortality were significantly lower in the protocol group. Surgical patients had a survival rate of 92.4%. Therefore, the current protocol for sepsis management did improve mortality. Further studies with a larger number of patients are in progress.
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Affiliation(s)
- Tarik Wasfie
- Department of Surgery/Trauma, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Anna Buzadzhi
- Department of Surgery/Trauma, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | | | - Chase Cataline
- College of Osteopathic Medicine, 3078Michigan State University, East Lansing, MI, USA
| | - Ada Ahmady
- College of Osteopathic Medicine, 3078Michigan State University, East Lansing, MI, USA
| | - Victor Wong
- College of Osteopathic Medicine, 3078Michigan State University, East Lansing, MI, USA
| | - Jared Hicken
- 14412AT. Still University, School of Osteopathic Medicine, Kirksville, MO, USA
| | - Mikayla Depuydt
- College of Osteopathic Medicine, 3078Michigan State University, East Lansing, MI, USA
| | - Jennifer Hella
- Department of Academic Research, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Barbara Senger
- 14412AT. Still University, School of Osteopathic Medicine, Kirksville, MO, USA
| | - Kimberly Barber
- Department of Academic Research, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
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13
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Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine. Crit Care Med 2021; 50:37-49. [PMID: 34259453 DOI: 10.1097/ccm.0000000000005147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions. DATA SOURCES AND STUDY SELECTION Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product. DATA EXTRACTION AND SYNTHESIS The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations. CONCLUSIONS Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.
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Maharaj R, McGuire A, Street A. Association of Annual Intensive Care Unit Sepsis Caseload With Hospital Mortality From Sepsis in the United Kingdom, 2010-2016. JAMA Netw Open 2021; 4:e2115305. [PMID: 34185067 PMCID: PMC8243236 DOI: 10.1001/jamanetworkopen.2021.15305] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Sepsis is associated with a high burden of inpatient mortality. Treatment in intensive care units (ICUs) that have more experience treating patients with sepsis may be associated with lower mortality. OBJECTIVE To assess the association between the volume of patients with sepsis receiving care in an ICU and hospital mortality from sepsis in the UK. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from adult patients with sepsis from 231 UK ICUs between 2010 and 2016. Demographic and clinical data were extracted from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme database. Data were analyzed from January 1, 2010, to December 31, 2016. EXPOSURES Annual sepsis case volume in an ICU in the year of a patient's admission. MAIN OUTCOMES AND MEASURES Hospital mortality after ICU admission for sepsis assessed using a mixed-effects logistic model in a 3-level hierarchical structure based on the number of individual patients nested in years nested within ICUs. RESULTS Among 273 001 patients included in the analysis, the median age was 66 years (interquartile range, 53-76 years), 148 149 (54.3%) were male, and 248 275 (91.0%) were White. The mean ICNARC-2018 illness severity score was 21.0 (95% CI, 20.9-21.0). Septic shock accounted for 19.3% of patient admissions, and 54.3% of patients required mechanical ventilation. The median annual sepsis volume per ICU was 242 cases (interquartile range, 177-334 cases). The study identified a significant association between the volume of sepsis cases in the ICU and mortality from sepsis; in the logistic regression model, hospital mortality was significantly lower among patients admitted to ICUs in the highest quartile of sepsis volume compared with the lowest quartile (odds ratio [OR], 0.89; 95% CI, 0.82-0.96; P = .002). With volume modeled as a restricted cubic spline, treatment in a larger ICU was associated with lower hospital mortality. A lower annual volume threshold of 215 patients above which hospital mortality decreased significantly was found; 38.8% of patients were treated in ICUs below this threshold volume. There was no significant interaction between ICU volume and severity of illness as described by the ICNARC-2018 score (β [SE], -0.00014 [0.00024]; P = .57). CONCLUSIONS AND RELEVANCE The findings suggest that patients with sepsis in the UK have higher odds of survival if they are treated in an ICU with a larger sepsis case volume. The benefit of a high sepsis case volume was not associated with the severity of the sepsis episode.
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Affiliation(s)
- Ritesh Maharaj
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Critical Care, Kings College Hospital NHS Foundation Trust, London, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
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15
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Aliyu S, McGowan K, Hussain D, Kanawati L, Ruiz M, Yohannes S. Prevalence and Outcomes of Multi-Drug Resistant Blood Stream Infections Among Nursing Home Residents Admitted to an Acute Care Hospital. J Intensive Care Med 2021; 37:565-571. [PMID: 33938320 DOI: 10.1177/08850666211014450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The prevalence of multi-drug resistant organism (MDRO) colonization in nursing home residents has been well documented, but little is known about the impact of MDRO bloodstream infections (BSIs). The aim of this study was to assess the prevalence, cost, and outcomes of MDRO-BSI vs. non-MDRO-BSI among nursing home residents. DESIGN Retrospective cohort study. SETTING 960 bed tertiary academic medical center. PATIENTS Persons ≥18 years old admitted to an acute care tertiary hospital from Skilled Nursing Facilities with a diagnosis of sepsis between 2015 and 2018. INTERVENTIONS Retrospective analysis of prevalence and outcomes. MEASUREMENTS AND MAIN RESULTS Among patients admitted to the study hospital with a diagnosis of sepsis during the study period, 7% were from nursing homes. The prevalence of MDRO-BSI was 47%. We identified 54 (50%) gram positive BSIs, 48 (45%) gram negative BSI and 5 (5%) fungal BSI. Thirty-one (57%) of the gram-positive infections and 14 (30%) of the gram-negative infections were with MDROs. The prevalence of BSI organisms were Staphylococcus aureus in 24%, Escherichia coli in 14%, Proteus mirabilis in 13%, Staphylococcus epidermidis in 8%, Enterococcus faecalis in 7%, and Klebsiella pneumoniae in 6%. We found that intensive care unit length of stay (7 days vs 5 days, P = .009), direct cost ($13,639 vs $9,922, P = .027), and total cost ($23,752 vs $17,900 P = .032) were significantly higher in patients with MDRO-BSI vs. non-MDRO-BSI. Patients with MDRO-BSI were twice as likely to receive inappropriate empiric antiinfective therapy (31% vs 16%, P = .006) and were more likely to die (49.1% vs 29.6%, P = .049). CONCLUSION Nursing home residents have a high prevalence of MDRO-BSI, which is associated with higher risk of receiving inappropriate initial anti-infective therapy, higher cost, higher ICU LOS, and higher mortality. Our research adds new information about the prevalence of fungemia in this population.
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Affiliation(s)
- Sainfer Aliyu
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Kevin McGowan
- Georgetown University School of Medicine, Washington, DC, USA
| | - Dilbi Hussain
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Lama Kanawati
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Maria Ruiz
- 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Seife Yohannes
- 8405MedStar Washington Hospital Center, Washington, DC, USA
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16
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Wong NZ, Schaubel DE, Reddy KR, Bittermann T. Transplant center experience influences spontaneous survival and waitlist mortality in acute liver failure: An analysis of the UNOS database. Am J Transplant 2021; 21:1092-1099. [PMID: 32741074 DOI: 10.1111/ajt.16234] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/15/2020] [Accepted: 07/19/2020] [Indexed: 01/25/2023]
Abstract
Transplant centers coordinate complex care in acute liver failure (ALF), for which liver transplant (LT) can be lifesaving. We studied associations between waitlist outcomes and center (1) ALF waitlist volume (low: <20; medium: 20-39; high: 40+ listings) and (2) total LT volume (<600, 600-1199, 1200+ LTs) in a retrospective cohort of 3248 adults with ALF listed for LT at 92 centers nationally from 2002 to 2019. Predicted outcome probabilities (LT, died/too sick, spontaneous survival [SS]) were obtained with multinomial regression, and observed-to-expected ratios were calculated. Median center outcome rates were 72.6% LT, 18.2% died/too sick, and 6.1% SS. SS was significantly higher with greater center ALF volume (median 0% for low-, 5.9% for medium-, and 8.6% for high-volume centers; P = .039), while waitlist mortality was highest at low-volume centers (median 21.4%, IQR: 16.1%-26.7%; P = .042). Significant heterogeneity in center performance was observed for waitlist mortality (observed-to-expected ratio range: 0-4.1) and particularly for SS (0-6.4), which persisted despite accounting for recipient case mix. This novel study demonstrates that increased center experience is associated with greater SS and reduced waitlist mortality for ALF. More-focused management pathways are needed to improve ALF outcomes at less-experienced centers and to identify opportunities for improvement at large.
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Affiliation(s)
- Natalie Z Wong
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K Rajender Reddy
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Nygaard RM, Endorf FW. Differences in Treatment of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis at Burn Centers and Nonburn Centers. J Burn Care Res 2020; 41:945-950. [PMID: 32498082 DOI: 10.1093/jbcr/iraa082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and Stevens-Johnson/TEN overlap syndrome (SJS/TEN) are severe exfoliative skin disorders resulting primarily from allergic drug reactions and sometimes from viral causes. Because of the significant epidermal loss in many of these patients, many of them end up receiving treatment at a burn center for expertise in the care of large wounds. Previous work on the treatment of this disease focused only on the differences in care of the same patients treated at nonburn centers and then transferred to burn centers. We wanted to explore whether patients had any differences in care or outcomes when they received definitive treatment at burn centers and nonburn centers. We queried the National Inpatient Sample database from 2016 for patients with SJS, SJS/TEN, and TEN diagnoses. We considered burn centers as those with greater than 10 burn transfers to their center and fewer than 5 burn transfers out of their center in a year. Multivariable logistic regression assessed factors associated with treatment at a burn center and mortality. Using the National Inpatient Sample, a total of 1164 patients were identified. These were divided into two groups, nonburn centers vs burn centers, and those groups were compared for demographic characteristics as well as variables in their hospital course and outcome. Patients treated at nonburn centers were more likely to have SJS and patients treated at burn centers were more likely to have both SJS/TEN and TEN. Demographics were similar between treatment locations, though African-Americans were more likely to be treated at a burn center. Burn centers had higher rates of patients with extreme severity and mortality risks and a longer length of stay. However, burn centers had similar actual mortality compared to nonburn centers. Patients treated at burn centers had higher charges and were more likely to be transferred to long-term care after their hospital stay. The majority of patients with exfoliative skin disorders are still treated at nonburn centers. Patients with SJS/TEN and TEN were more likely to be treated at a burn center. Patients treated at burn centers appear to have more severe disease but similar mortality to those treated at nonburn centers. Further study is needed to determine whether patients with these disorders do indeed benefit from transfer to a burn center.
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Hospital-level variation in the development of persistent critical illness. Intensive Care Med 2020; 46:1567-1575. [PMID: 32500182 DOI: 10.1007/s00134-020-06129-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/20/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Patients with persistent critical illness may account for up to half of all intensive care unit (ICU) bed-days. It is unknown if there is hospital variation in the development of persistent critical illness and if hospital performance affects the incidence of persistent critical illness. METHODS This is a retrospective analysis of Veterans admitted to the Veterans Administration (VA) ICUs from 2015 to 2017. Hospital performance was defined by the risk- and reliability-adjusted 30-day mortality. Persistent critical illness was defined as an ICU length of stay of at least 11 days. We used 2-level multilevel logistic regression models to assess variation in risk- and reliability-adjusted probabilities in the development of persistent critical illness. RESULTS In the analysis of 100 hospitals which encompassed 153,512 hospitalizations, 4.9% (N = 7640/153,512) developed persistent critical illness. There was variation in the development of persistent critical illness despite controlling for patient characteristics (intraclass correlation: 0.067, 95% CI 0.049-0.091). Hospitals with higher risk- and reliability-adjusted 30-day mortality had higher probabilities of developing persistent critical illness (predicted probability: 0.057, 95% CI 0.051-0.063, p < 0.01) compared to those with lower risk- and reliability-adjusted 30-day mortality (predicted probability: 0.046, 95% CI 0.041-0.051, p < 0.01). The median odds ratio was 1.4 (95% CI 1.33-1.49) implying that, for two patients with the same physiology on admission at two different VA hospitals, the patient admitted to the hospital with higher adjusted mortality would have 40% greater odds of developing persistent critical illness. CONCLUSION Hospitals with higher risk- and reliability-adjusted 30-day mortality have a higher probability of developing persistent critical illness. Understanding the drivers of this variation may identify modifiable factors contributing to the development of persistent critical illness.
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Abstract
OBJECTIVES The Centers for Medicare and Medicaid Services requires hospitals to report compliance with a sepsis treatment bundle as part of its Inpatient Quality Reporting Program. We used recently released data from this program to characterize national performance on the sepsis measure, known as SEP-1. DESIGN Cross-sectional study of United States hospitals participating in the Centers for Medicare and Medicaid Services Hospital Inpatient Quality Reporting Program linked to Centers for Medicare and Medicaid Services' Healthcare Cost Reporting Information System. SETTING General, short-stay, acute-care hospitals in the United States. MEASUREMENTS AND MAIN RESULTS We examined the hospital factors associated with reporting SEP-1 data, the hospital factors associated with performance on the SEP-1 measure, and the relationship between SEP-1 performance and performance on other quality measures related to time-sensitive medical conditions. A total of 3,283 hospitals were eligible for the analysis, of which 2,851 (86.8%) reported SEP-1 performance data. SEP-1 reporting was more common in larger, nonprofit hospitals. The most common reason for nonreporting was an inadequate case volume. Among hospitals reporting SEP-1 performance data, overall bundle compliance was generally low, but it varied widely across hospitals (mean and SD: 48.9% ± 19.4%). Compared with hospitals with worse SEP-1 performance, hospitals with better SEP-1 performance tended to be smaller, for-profit, nonteaching, and with intermediate-sized ICUs. Better hospital performance on SEP-1 was associated with higher rates of timely head CT interpretation for stroke patients (rho = 0.16; p < 0.001), more frequent aspirin administration for patients with chest pain or heart attacks (rho = 0.24; p < 0.001) and shorter median time to electrocardiogram for patients with chest pain (rho = -0.12; p < 0.001). CONCLUSIONS The majority of eligible hospitals reported SEP-1 data, and overall bundle compliance was highly variable. SEP-1 performance was associated with structural hospital characteristics and performance on other measures of hospital quality, providing preliminary support for SEP-1 performance as a marker of timely hospital sepsis care.
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20
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Tektonidou MG, Dasgupta A, Ward MM. Interhospital variation in mortality among patients with systemic lupus erythematosus and sepsis in the USA. Rheumatology (Oxford) 2020; 58:1794-1801. [PMID: 31323667 DOI: 10.1093/rheumatology/kez103] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 02/25/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To determine whether the risk of mortality in patients with SLE hospitalized with sepsis varies among hospitals in the USA. METHODS We used the National Inpatient Sample (2002-2011) to obtain national population-based data on outcomes for adults with SLE admitted with sepsis, and compared it with that for patients without SLE admitted with sepsis at the same hospital. We computed expected mortality based on patient demographic characteristics, comorbidities and major organ dysfunction, and calculated observed/expected (O/E) mortality ratios separately for patients with SLE and without SLE for each hospital. We then computed the ratio of these O/E ratios within hospitals to assess relative SLE mortality. We considered hospitals with a risk ratio (RR) of ⩾2.0 as having high relative SLE mortality. RESULTS Among 424 hospitals that treated a total of 4024 patients with SLE and sepsis, the risk of in-hospital mortality varied from 0% to 60% (median 11.1%). The RR ranged from 0 to 9.75, with a median of 0.84, indicating that O/E mortality was similar in patients with and without SLE at the average hospital. Sixty-one hospitals (14.4%) had a RR of ⩾2.0, indicating higher mortality among patients with SLE. Hospitals that on average treated ⩾3.9 patients with SLE and sepsis annually were less likely to have a RR of ⩾2.0 than hospitals that treated fewer patients (10% vs 17%; P = 0.004). CONCLUSION Mortality among patients with SLE and sepsis varied widely between hospitals, and was lower at hospitals that treated more of these patients.
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Affiliation(s)
- Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Abhijit Dasgupta
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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He H, Ma X, Su L, Wang L, Guo Y, Shan G, He HJ, Zhou X, Liu D, Long Y, Zhao Y, Zhang S. Effects of a national quality improvement program on ICUs in China: a controlled pre-post cohort study in 586 hospitals. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:73. [PMID: 32131872 PMCID: PMC7057512 DOI: 10.1186/s13054-020-2790-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/14/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Patient safety and critical care quality remain a challenging issue in the ICU. However, the effects of the national quality improvement (QI) program remain unknown in China. METHODS A national ICU QI program was implemented in a controlled cohort of 586 hospitals from 2016 to 2018. The effects of the QI program on critical care quality were comprehensively investigated. MAIN RESULTS A total of 81,461,554 patients were enrolled in 586 hospitals, and 1,587,724 patients were admitted to the ICU over 3 years. In 2018, there was a significantly higher number of ICU beds (2016 vs. 2018: 10668 vs. 13,661, P = 0.0132) but a lower doctor-to-bed ratio (2016 vs. 2018: 0.64 (0.50, 0.83) vs. 0.60 (0.45, 0.75), P = 0.0016) and nurse-to-bed ratio (2016 vs. 2018: 2.00 (1.64, 2.50) vs. 2.00 (1.50, 2.40), P = 0.031) than in 2016. Continuous and significant improvements in the ventilator-associated pneumonia (VAP) incidence rate, microbiology detection rate before antibiotic use and deep vein thrombosis (DVT) prophylaxis rate were associated with the implementation of the QI program (VAP incidence rate (per 1000 ventilator-days), 2016 vs. 2017 vs. 2018: 11.06 (4.23, 22.70) vs. 10.20 (4.25, 23.94) vs. 8.05 (3.13, 17.37), P = 0.0002; microbiology detection rate before antibiotic use (%), 2016 vs. 2017 vs. 2018: 83.91 (49.75, 97.87) vs. 84.14 (60.46, 97.24) vs. 90.00 (69.62, 100), P < 0.0001; DVT prophylaxis rate, 2016 vs. 2017 vs. 2018: 74.19 (33.47, 96.16) vs. 71.70 (38.05, 96.28) vs. 83.27 (47.36, 97.77), P = 0.0093). Moreover, the 6-h SSC bundle compliance rates in 2018 were significantly higher than those in 2016 (6-h SSC bundle compliance rate, 2016 vs. 2018: 64.93 (33.55, 93.06) vs. 76.19 (46.88, 96.67)). A significant change trend was not found in the ICU mortality rate from 2016 to 2018 (ICU mortality rate (%), 2016 vs. 2017 vs. 2018: 8.49 (4.42, 14.82) vs. 8.95 (4.89, 15.70) vs. 9.05 (5.12, 15.80), P = 0.1075). CONCLUSIONS The relationship between medical human resources and ICU overexpansion was mismatched during the past 3 years. The implementation of a national QI program improved ICU performance but did not reduce ICU mortality.
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Affiliation(s)
- Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xudong Ma
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Longxiang Su
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Lu Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yanhong Guo
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Guangliang Shan
- Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) & School of Basic Medicine, Peking Union Medical College, Beijing, 100730, China
| | - Hui Jing He
- Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) & School of Basic Medicine, Peking Union Medical College, Beijing, 100730, China
| | - Xiang Zhou
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
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Abstract
OBJECTIVES Prior studies investigating hospital mechanical ventilation volume-outcome associations have had conflicting findings. Volume-outcome relationships within contemporary mechanical ventilation practices are unclear. We sought to determine associations between hospital mechanical ventilation volume and patient outcomes. DESIGN Retrospective cohort study. SETTING The California Patient Discharge Database 2016. PATIENTS Adult nonsurgical patients receiving mechanical ventilation. INTERVENTIONS The primary outcome was hospital death with secondary outcomes of tracheostomy and 30-day readmission. We used multivariable generalized estimating equations to determine the association between patient outcomes and hospital mechanical ventilation volume quartile. MEASUREMENTS AND MAIN RESULTS We identified 51,689 patients across 274 hospitals who required mechanical ventilation in California in 2016. 38.2% of patients died in the hospital with 4.4% receiving a tracheostomy. Among survivors, 29.5% required readmission within 30 days of discharge. Patients admitted to high versus low volume hospitals had higher odds of death (quartile 4 vs quartile 1 adjusted odds ratio, 1.40; 95% CI, 1.17-1.68) and tracheostomy (quartile 4 vs quartile 1 adjusted odds ratio, 1.58; 95% CI, 1.21-2.06). However, odds of 30-day readmission among survivors was lower at high versus low volume hospitals (quartile 4 vs quartile 1 adjusted odds ratio, 0.77; 95% CI, 0.67-0.89). Higher hospital mechanical ventilation volume was weakly correlated with higher hospital risk-adjusted mortality rates (ρ = 0.16; p = 0.008). These moderately strong observations were supported by multiple sensitivity analyses. CONCLUSIONS Contrary to previous studies, we observed worse patient outcomes at higher mechanical ventilation volume hospitals. In the setting of increasing use of mechanical ventilation and changes in mechanical ventilation practices, multiple mechanisms of worse outcomes including resource strain are possible. Future studies investigating differences in processes of care between high and low volume hospitals are necessary.
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Double inter-hospital transfer in Sepsis patients presenting to the ED does not worsen mortality compared to single inter-hospital transfer. J Crit Care 2019; 56:49-57. [PMID: 31837601 DOI: 10.1016/j.jcrc.2019.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/13/2019] [Accepted: 11/29/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Sepsis is a leading cause of hospital deaths. Inter-hospital transfer is frequent in sepsis and is associated with increased mortality. Some sepsis patients undergo two inter-hospital transfers (double transfer). This study assessed the (1) prevalence, (2) associated risk factors, (3) associated mortality, and (4) hospital length-of-stay and costs of double-transfer of sepsis patients. MATERIALS AND METHODS Retrospective cohort study using 2005-2014 administrative claims data in Iowa. Multivariable generalized estimating equations adjusted for potential confounding variables, with a primary outcome of mortality. Secondary outcomes included hospital length-of-stay and costs. Hospital-specific cost-to-charge ratios estimated hospital costs. Hospitals were categorized into quintiles based on sepsis-volume. RESULTS Of 15,182 sepsis subjects, there were 45.2% non-transfers and 2.1% double-transfers. Double-transfers had worse mortality than non-transfers but not single-transfers. Of the non-transfers, 44.9% presented to a top sepsis-volume hospital compared to 22.8% of double-transfers and 25.1% of single-transfers. After transfer from first to second hospital, 93.4% of the single-transfers and 92.2% of the double-transfers were at a top sepsis-volume hospital. Double-transfers had longer length-of-stay and more in total hospital costs than single-transfers. CONCLUSIONS Double-transfer occurs in 2.1% of Iowa sepsis patients. Double-transfers had similar mortality and increased length of stay and costs compared to single-transfers.
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Immunosuppression and Heterogeneity in the Sepsis Volume-Outcome Relationship. Ann Am Thorac Soc 2019; 15:916-918. [PMID: 30067099 DOI: 10.1513/annalsats.201805-344ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Wani RJ, Tak HJ, Watanabe-Galloway S, Klepser DG, Wehbi NK, Chen LW, Wilson FA. Predictors and Costs of 30-Day Readmissions After Index Hospitalizations for Alcohol-Related Disorders in U.S. Adults. Alcohol Clin Exp Res 2019; 43:857-868. [PMID: 30861148 DOI: 10.1111/acer.14021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND In 2015, the Hospital Readmissions Reduction Program mandated financial penalties to hospitals with greater rates of readmissions for certain conditions. Alcohol-related disorders (ARD) are the fourth leading cause of 30-day readmissions. Yet, there is a dearth of national-level research to identify high-risk patient populations and predictors of 30-day readmission. This study examined patient- and hospital-level predictors for index hospitalizations with principal diagnosis of ARD and predicted the cost of 30-day readmissions. METHODS The 2014 Nationwide Readmissions Database was used to identify ARD-related index hospitalizations. Multivariable logistic regression was used to estimate patient- and hospital-level predictors for readmissions, and a 2-part model was used to predict the incremental cost conditional upon readmission. RESULTS In 2014, 285,767 index hospitalizations for ARD were recorded, and 18.9% of ARD-associated hospitalizations resulted in at least one 30-day readmission. Patients who were males, aged 45 to 64 years, Medicaid enrollees, living in urban and low-income areas, or with 1 to 2 comorbidities had high risk of readmission. Index hospitalization costs were higher among readmitted patients ($8,840 vs. $8,036, p < 0.01). Predicted mean costs for readmissions on index stay with ARD were greater among those aged 45 to 64 years ($1,908, p < 0.001), Medicare enrollees ($2,133, p < 0.001), rural residents ($1,841, p < 0.01), living in high-income areas ($1,876, p < 0.001), with 4 or more comorbidities ($2,415, p < 0.001), or admitted in large metropolitan hospitals ($2,032, p < 0.001), with large number of beds ($1,964, p < 0.001), with government ownership ($2,109, p < 0.001), or with low volume of ARD cases ($2,155, p < 0.001). CONCLUSIONS One in 5 ARD-related index hospitalizations resulted in a 30-day readmission. Overall, costs of index hospitalizations for ARD were $2.3 billion, of which $512 million were spent on hospitalizations that resulted in at least 1 readmission. There is a need to develop patient-centric health programs to reduce readmission rates and costs among ARD patients.
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Affiliation(s)
- Rajvi J Wani
- College of Education and Human Sciences, University of Nebraska-Lincoln, Lincoln, Nebraska
| | - Hyo Jung Tak
- Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Shinobu Watanabe-Galloway
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Donald G Klepser
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska
| | - Nizar K Wehbi
- Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Li-Wu Chen
- Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Fernando A Wilson
- Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Differences in effect of early enteral nutrition on mortality among ventilated adults with shock requiring low-, medium-, and high-dose noradrenaline: A propensity-matched analysis. Clin Nutr 2019; 39:460-467. [PMID: 30808573 DOI: 10.1016/j.clnu.2019.02.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/18/2019] [Accepted: 02/09/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Despite extensive research on early enteral nutrition (EEN), it remains unclear whether EEN is effective for patients with shock requiring vasopressors. This study aimed to compare outcomes between EEN and late enteral nutrition (LEN) in ventilated patients with shock requiring low-, medium-, or high-dose noradrenaline. METHODS Using a national inpatient database in Japan, we identified ventilated patients admitted to intensive care units who had shock requiring catecholamines (noradrenaline or dobutamine) from July 2010 to March 2016. We defined patients who started enteral nutrition within 2 days after starting mechanical ventilation as EEN group and the others as LEN group. Propensity score matching was performed between patients undergoing EEN and LEN in each of the low- (<0.1 μg/kg/min), medium- (0.1-0.3 μg/kg/min), and high-dose (≥0.3 μg/kg/min) noradrenaline groups. RESULTS We identified 52,563 eligible patients during the 69-month study period, including 38,488, 11,042, and 3033 patients in the low-, medium-, and high-dose noradrenaline groups, respectively. One-to-two propensity score matching created 5,969, 2,162, and 477 one-to-two matched pairs in the low-, medium-, and high-dose noradrenaline groups, respectively. The 28-day mortality rate was significantly lower in the EEN than LEN group in the low-dose noradrenaline group (risk difference, -2.9%; 95% confidence interval [CI], -4.5% to -1.3%) and in the medium-dose noradrenaline group (risk difference, -6.8%; 95% CI, -9.6% to -4.0%). In the high-dose noradrenaline group, 28-day mortality did not differ significantly between the EEN and LEN groups (absolute risk difference, -1.4%; 95% CI, -7.4%-4.7%). CONCLUSIONS Although the size of the subgroup requiring high-dose noradrenaline may have been too small to demonstrate a significant difference, the results suggest that EEN was associated with a reduction in mortality in ventilated adults treated with low- or medium-dose noradrenaline but not in those requiring high-dose noradrenaline.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Chimunda T, Silver SA, Kuwornu JP, Li L, Nash DM, Dixon SN, Adhikari NK, Acedillo RR, Harel Z, Kitchlu A, Garg AX, Bell CM, Sood MM, Kim JS, Wald R. Hospital case volume and clinical outcomes in critically ill patients with acute kidney injury treated with dialysis. J Crit Care 2018; 48:276-282. [DOI: 10.1016/j.jcrc.2018.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 06/15/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
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A Cost-Benefit Analysis of Automated Physiological Data Acquisition Systems Using Data-Driven Modeling. JOURNAL OF HEALTHCARE INFORMATICS RESEARCH 2018; 3:245-263. [DOI: 10.1007/s41666-018-0040-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 10/27/2022]
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O'Shea AMJ, Fortis S, Vaughan Sarrazin M, Moeckli J, Yarbrough WC, Schacht Reisinger H. Outcomes comparison in patients admitted to low complexity rural and urban intensive care units in the Veterans Health Administration. J Crit Care 2018; 49:64-69. [PMID: 30388490 DOI: 10.1016/j.jcrc.2018.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/15/2018] [Accepted: 10/18/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To evaluate mortality, length of stay, and inter-hospital transfer in the Veteran Health Administration (VHA) among low complexity Intensive Care Unit (ICU) patients. MATERIALS AND METHOD Retrospective study of adult ICU admissions identified in VHA Medical SAS®; 2010-2015 at Veterans Affairs (VA) Medical Centers. Facilities classified by the Rural Urban Commuting Area code algorithm as large rural (referred to as rural) (N = 6) or urban (N = 33). RESULTS In rural hospitals, patients (N = 9665) were less likely to have a respiratory (12.9% v. 18.9%; p < .001) diagnosis, more likely diagnosed with sepsis (17.6% v. 4.9%), and had a higher illness severity score (42.0 vs. 41.4; p = .01) compared to urban (N = 65,846) counterparts. Mortality within ICU did not vary across facility rurality. In unadjusted analyses, facility rurality (rural vs. urban) was associated with reduced inter-hospital transfers (OR = 0.74; 95% CI = [0.69, 0.80]; p < .001) and a shorter ICU length of stay (RR = 0.82; 95% CI = [0.74, 0.91]; p < .001). This did not hold when the hierarchical data was accounted for. CONCLUSIONS Despite challenges, low complexity ICUs in rural VA facilities fare similarly to urban counterparts. Being part of a national healthcare system may have benefits to explore in sustaining critical care access in rural areas outside the VA healthcare system.
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Affiliation(s)
- Amy M J O'Shea
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 W, Iowa City, IA 52246, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Spyridon Fortis
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 W, Iowa City, IA 52246, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Mary Vaughan Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 W, Iowa City, IA 52246, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Jane Moeckli
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 W, Iowa City, IA 52246, USA
| | - W C Yarbrough
- Department Pulmonary/Critical Care, VA North Texas Healthcare System, Dallas, TX, USA; Department of Internal Medicine, U.T. Southwestern Medical Center, Dallas, TX, USA
| | - Heather Schacht Reisinger
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, 601 Hwy 6 W, Iowa City, IA 52246, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
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Greenberg JA, Hohmann SF, James BD, Shah RC, Hall JB, Kress JP, David MZ. Hospital Volume of Immunosuppressed Patients with Sepsis and Sepsis Mortality. Ann Am Thorac Soc 2018; 15:962-969. [PMID: 29856657 PMCID: PMC6322036 DOI: 10.1513/annalsats.201710-819oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 06/01/2018] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Immunosuppressive medical conditions are risk factors for mortality from severe infections. It is unknown whether hospital characteristics affect this risk. OBJECTIVES To determine whether the odds of death for an immunosuppressed patient with sepsis relative to a nonimmunosuppressed patient with sepsis varies according to the hospital's yearly case volume of immunosuppressed patients with sepsis. METHODS Patients with sepsis at hospitals in the Vizient database were characterized as immunosuppressed or not immunosuppressed on the basis of diagnosis codes and medication use. Hospitals were grouped into quartiles based on their average volumes of immunosuppressed patients with sepsis per year. Multilevel logistic regression with clustering of patients by hospital was used to determine whether the odds of in-hospital death from sepsis owing to a suppressed immune state varied by hospital quartile. RESULTS There were 350,183 patients with sepsis at 60 hospitals in the Vizient database from 2010 to 2012. Immunosuppressed patients with sepsis at the 15 hospitals in the lowest quartile (64 to 224 immunosuppressed patients with sepsis per year) had an increased odds of in-hospital death relative to nonimmunosuppressed patients with sepsis at these hospitals (adjusted odds ratio, 1.38; 95% confidence interval, 1.27-1.50; P < 0.001). The odds of in-hospital death for immunosuppressed patients with sepsis relative to nonimmunosuppressed patients with sepsis was similar for patients at hospitals in the second, third, and fourth quartiles (225 to 1,056 immunosuppressed patients with sepsis per year). The adjusted odds of death from sepsis owing to a suppressed immune state of 1.21 (95% confidence interval, 1.18-1.25; P < 0.001) for patients at these 45 hospitals was significantly less than for patients at the 15 hospitals in the lowest quartile (P = 0.004 for difference). CONCLUSIONS The risk of death from sepsis owing to a suppressed immune state was greatest at hospitals with the lowest volume of immunosuppressed patients with sepsis. Further study is needed to determine whether this finding is related to differences in patient characteristics or in care delivery at hospitals with different amounts of exposure to immunosuppressed patients.
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Affiliation(s)
- Jared A. Greenberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine
| | - Samuel F. Hohmann
- Department of Health Systems Management
- Center for Advanced Analytics, Vizient, Chicago, Illinois
| | - Bryan D. James
- Department of Internal Medicine
- Rush Alzheimer’s Disease Center, and
| | - Raj C. Shah
- Rush Alzheimer’s Disease Center, and
- Department of Family Medicine, Rush University Medical Center, Chicago, Illinois
| | - Jesse B. Hall
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - John P. Kress
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois; and
| | - Michael Z. David
- Division of Infectious Disease, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Chaudhary NS, Donnelly JP, Wang HE. Racial Differences in Sepsis Mortality at U.S. Academic Medical Center-Affiliated Hospitals. Crit Care Med 2018; 46:878-883. [PMID: 29438109 PMCID: PMC5953774 DOI: 10.1097/ccm.0000000000003020] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the racial disparities in severe sepsis hospitalizations and outcomes in U.S. academic medical center-affiliated hospitals. DESIGN Retrospective analysis of sepsis hospitalizations. SETTINGS U.S. academic medical center-affiliated hospitals participating in Vizient Consortium from 2012 to 2014. PATIENTS Sepsis hospitalizations using International Classification of Diseases, Ninth revision, discharge diagnoses codes defined by the Angus method. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared rates of sepsis hospitalization, ICU admission, organ dysfunction, and hospital mortality between blacks and whites. We repeated the analyses stratified by community-acquired, healthcare-associated, and hospital-acquired sepsis subtypes. Of 10,244,780 hospitalizations in our cohort, 1,114,386 (10.9%) had sepsis. Sepsis subtypes included community-acquired sepsis (61.8%), healthcare-associated sepsis (23.8%), and hospital-acquired sepsis (14.4%). Although the proportion of discharges with sepsis was lower for blacks than whites (106.72 vs 109.43 per 1,000 hospitalizations; p < 0.001), the proportion of black sepsis hospitalizations was higher for individuals greater than 30 years old. Blacks exhibited lower adjusted sepsis hospital mortality than whites (odds ratio, 0.85; 95% CI, 0.84-0.86). The adjusted odds of hospital mortality following community-acquired, healthcare-associated, and hospital-acquired sepsis were lower for blacks than whites. CONCLUSIONS In this current series of hospital discharges at U.S. academic medical center-affiliated hospitals, blacks exhibited lower adjusted rates of sepsis hospitalizations and mortality than whites.
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Affiliation(s)
- Ninad S. Chaudhary
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - John P. Donnelly
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Henry E. Wang
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, TX
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Gutsche JT, Miano TA, Vernick W, Raiten J, Bermudez C, Vallabjoysula P, Milewski K, Szeto W, Fall ML, Williams ML, Patel P, Mikkelsen ME, Chiu C, Ramakrishna H, Canon J, Augoustides JG. Does a Mobile ECLS Program Reduce Mortality for Patients Transported for ECLS Therapy for Severe Acute Respiratory Failure? J Cardiothorac Vasc Anesth 2017; 32:1137-1141. [PMID: 29153427 DOI: 10.1053/j.jvca.2017.08.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To understand if mobile extracorporeal membrane oxygenation reduces patient mortality during and after transport of patients requiring extracorporeal membrane oxygenation for acute respiratory distress syndrome. DESIGN Retrospective chart review. SETTING University affiliated tertiary care hospitals. PARTICIPANTS Seventy-seven patients. INTERVENTIONS Introduction of a mobile extracorporeal membrane oxygenation (ECMO) program designed to facilitate the implementation of ECMO at outside hospitals in patients too unstable for transport for ECMO. MEASUREMENTS AND MAIN RESULTS The 28-day in-hospital mortality was significantly lower in the post-mobile group (12/51 [23.5%] v 12/24 [50%], adjusted risk difference: 28.6%, [95% CI 4.7-52.5, p = 0.011]). CONCLUSIONS These findings suggest that patients with severe acute respiratory failure who require transport to a referral center for extracorporeal life support may benefit from the availability of a mobile extracorporeal life support team.
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Affiliation(s)
- Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA.
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William Vernick
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Jesse Raiten
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Prashant Vallabjoysula
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Karianna Milewski
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Wilson Szeto
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Meghan Lane Fall
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Matthew L Williams
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Prakash Patel
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Mark E Mikkelsen
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania Health System, Philadelphia, PA
| | - Cornel Chiu
- Drexel University College of Medicine, Philadelphia, PA
| | | | - Jeremy Canon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
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Association Between Hospital Case Volume of Sepsis, Adherence to Evidence-Based Processes of Care and Patient Outcomes. Crit Care Med 2017; 45:980-988. [PMID: 28350646 DOI: 10.1097/ccm.0000000000002409] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES We sought to explore potential mechanisms underlying hospital sepsis case volume-mortality associations by investigating implementation of evidence-based processes of care. DESIGN Retrospective cohort study. We determined associations of sepsis case volume with three evidence-based processes of care (lactate measurement during first hospital day, norepinephrine as first vasopressor, and avoidance of starch-based colloids) and assessed their role in mediation of case volume-mortality associations. SETTING Enhanced administrative data (Premier, Charlotte, NC) from 534 U.S. hospitals. SUBJECTS A total of 287,914 adult patients with sepsis present at admission between July 2010 and December 2012 of whom 58,045 received a vasopressor for septic shock during the first 2 days of hospitalization. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among patients with sepsis, 1.9% received starch, and among patients with septic shock, 68.3% had lactate measured and 64% received norepinephrine as initial vasopressor. Patients at hospitals with the highest case volume were more likely to have lactate measured (adjusted odds ratio quartile 4 vs quartile 1, 2.8; 95% CI, 2.1-3.7) and receive norepinephrine as initial vasopressor (adjusted odds ratio quartile 4 vs quartile 1, 2.1; 95% CI, 1.6-2.7). Case volume was not associated with avoidance of starch products (adjusted odds ratio quartile 4 vs quartile 1, 0.73; 95% CI, 0.45-1.2). Adherence to evidence-based care was associated with lower hospital mortality (adjusted odds ratio, 0.81; 95% CI, 0.70-0.94) but did not strongly mediate case volume-mortality associations (point estimate change ≤ 2%). CONCLUSIONS In a large cohort of U.S. patients with sepsis, select evidence-based processes of care were more likely implemented at high-volume hospitals but did not strongly mediate case volume-mortality associations. Considering processes and case volume when regionalizing sepsis care may maximize patient outcomes.
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Abstract
This review documents important progress made in 2015 in the field of critical care. Significant advances in 2015 included further evidence for early implementation of low tidal volume ventilation as well as new insights into the role of open lung biopsy, diaphragmatic dysfunction, and a potential mechanism for ventilator-induced fibroproliferation. New therapies, including a novel low-flow extracorporeal CO2 removal technique and mesenchymal stem cell-derived microparticles, have also been studied. Several studies examining the role of improved diagnosis and prevention of ventilator-associated pneumonia also showed relevant results. This review examines articles published in the American Journal of Respiratory and Critical Care Medicine and other major journals that have made significant advances in the field of critical care in 2015.
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Affiliation(s)
- Martin Dres
- 1 Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care and
| | - Jordi Mancebo
- 3 Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Gerard F Curley
- 1 Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care and.,4 Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; and
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Herrán-Monge R, Muriel-Bombín A, García-García MM, Merino-García PA, Martínez-Barrios M, Andaluz D, Ballesteros JC, Domínguez-Berrot AM, Moradillo-Gonzalez S, Macías S, Álvarez-Martínez B, Fernández-Calavia MJ, Tarancón C, Villar J, Blanco J. Epidemiology and Changes in Mortality of Sepsis After the Implementation of Surviving Sepsis Campaign Guidelines. J Intensive Care Med 2017. [PMID: 28651474 DOI: 10.1177/0885066617711882] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To determine the epidemiology and outcome of severe sepsis and septic shock after 9 years of the implementation of the Surviving Sepsis Campaign (SSC) and to build a mortality prediction model. METHODS This is a prospective, multicenter, observational study performed during a 5-month period in 2011 in a network of 11 intensive care units (ICUs). We compared our findings with those obtained in the same ICUs in a study conducted in 2002. RESULTS The current cohort included 262 episodes of severe sepsis and/or septic shock, and the 2002 cohort included 324. The prevalence was 14% (95% confidence interval: 12.5-15.7) with no differences to 2002. The population-based incidence was 31 cases/100 000 inhabitants/year. Patients in 2011 had a significantly lower Acute Physiology and Chronic Health Evaluation II (APACHE II; 21.9 ± 6.6 vs 25.5 ± 7.07), Logistic Organ Dysfunction Score (5.6 ± 3.2 vs 6.3 ± 3.6), and Sequential Organ Failure Assessment (SOFA) scores on day 1 (8 ± 3.5 vs 9.6 ± 3.7; P < .01). The main source of infection was intraabdominal (32.5%) although microbiologic isolation was possible in 56.7% of cases. The 2011 cohort had a marked reduction in 48-hour (7% vs 14.8%), ICU (27.2% vs 48.2%), and in-hospital (36.7% vs 54.3%) mortalities. Most relevant factors associated with death were APACHE II score, age, previous immunosuppression and liver insufficiency, alcoholism, nosocomial infection, and Delta SOFA score. CONCLUSION Although the incidence of sepsis/septic shock remained unchanged during a 10-year period, the implementation of the SSC guidelines resulted in a marked decrease in the overall mortality. The lower severity of patients on ICU admission and the reduced early mortality suggest an improvement in early diagnosis, better initial management, and earlier antibiotic treatment.
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Affiliation(s)
- Rubén Herrán-Monge
- 1 Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | | | | | | | | | - David Andaluz
- 3 Intensive Care Unit, Hospital Clínico Universitario, Valladolid, Spain
| | | | | | | | - Santiago Macías
- 7 Intensive Care Unit, Hospital General de Segovia, Segovia, Spain
| | | | | | | | - Jesús Villar
- 11 CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,12 Multidisciplinary Organ Dysfunction Evaluation Research Network (MODERN), Hospital Universitario Dr Negrin, Las Palmas de Gran Canaria, Spain
| | - Jesús Blanco
- 1 Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain.,11 CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, Lemeshow S, Osborn T, Terry KM, Levy MM. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med 2017; 376:2235-2244. [PMID: 28528569 PMCID: PMC5538258 DOI: 10.1056/nejmoa1703058] [Citation(s) in RCA: 1370] [Impact Index Per Article: 171.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In 2013, New York began requiring hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. METHODS We studied data from patients with sepsis and septic shock that were reported to the New York State Department of Health from April 1, 2014, to June 30, 2016. Patients had a sepsis protocol initiated within 6 hours after arrival in the emergency department and had all items in a 3-hour bundle of care for patients with sepsis (i.e., blood cultures, broad-spectrum antibiotic agents, and lactate measurement) completed within 12 hours. Multilevel models were used to assess the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. We also examined the times to the administration of antibiotics and to the completion of an initial bolus of intravenous fluid. RESULTS Among 49,331 patients at 149 hospitals, 40,696 (82.5%) had the 3-hour bundle completed within 3 hours. The median time to completion of the 3-hour bundle was 1.30 hours (interquartile range, 0.65 to 2.35), the median time to the administration of antibiotics was 0.95 hours (interquartile range, 0.35 to 1.95), and the median time to completion of the fluid bolus was 2.56 hours (interquartile range, 1.33 to 4.20). Among patients who had the 3-hour bundle completed within 12 hours, a longer time to the completion of the bundle was associated with higher risk-adjusted in-hospital mortality (odds ratio, 1.04 per hour; 95% confidence interval [CI], 1.02 to 1.05; P<0.001), as was a longer time to the administration of antibiotics (odds ratio, 1.04 per hour; 95% CI, 1.03 to 1.06; P<0.001) but not a longer time to the completion of a bolus of intravenous fluids (odds ratio, 1.01 per hour; 95% CI, 0.99 to 1.02; P=0.21). CONCLUSIONS More rapid completion of a 3-hour bundle of sepsis care and rapid administration of antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality. (Funded by the National Institutes of Health and others.).
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Affiliation(s)
- Christopher W Seymour
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Foster Gesten
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Hallie C Prescott
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Marcus E Friedrich
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Theodore J Iwashyna
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Gary S Phillips
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Stanley Lemeshow
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Tiffany Osborn
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Kathleen M Terry
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
| | - Mitchell M Levy
- From the Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh School of Medicine, and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center - both in Pittsburgh (C.W.S.); the New York State Department of Health, Albany (F.G., M.E.F.), and IPRO, Lake Success (G.S.P., K.M.T.) - both in New York; the University of Michigan and the Veterans Affairs Center for Clinical Management Research - both in Ann Arbor (H.C.P., T.J.I.); the Division of Biostatistics, Ohio State University College of Public Health, Columbus (S.L.); Washington University, St. Louis (T.O.); and the Warren Alpert Medical School at Brown University, Providence, RI (M.M.L.)
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Case Volume-Outcomes Associations Among Patients With Severe Sepsis Who Underwent Interhospital Transfer. Crit Care Med 2017; 45:615-622. [PMID: 28151758 DOI: 10.1097/ccm.0000000000002254] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Case volume-outcome associations bolster arguments to regionalize severe sepsis care, an approach that may necessitate interhospital patient transfers. Although transferred patients may most closely reflect care processes involved with regionalization, associations between sepsis case volume and outcomes among transferred patients are unclear. We investigated case volume-outcome associations among patients with severe sepsis transferred from another hospital. DESIGN Serial cross-sectional study using the Nationwide Inpatient Sample. SETTING United States nonfederal hospitals, years 2003-2011. PATIENTS One hundred forty-one thousand seven hundred seven patients (weighted national estimate of 717,732) with severe sepsis transferred from another acute care hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We examined associations between quintiles of annual hospital severe sepsis case volume for the receiving hospital and in-hospital mortality among transferred patients with severe sepsis. Secondary outcomes included hospital length of stay and total charges. Transferred patients accounted for 13.2% of hospitalized severe sepsis cases. In-hospital mortality was 33.2%, with median length of stay 11 days (interquartile range, 5-22), and median total charge $70,722 (interquartile range, $30,591-$159,013). Patients transferred to highest volume hospitals had higher predicted mortality risk, greater number of acutely dysfunctional organs, and lower adjusted in-hospital mortality when compared with the lowest-volume hospitals (odds ratio, 0.80; 95% CI, 0.67-0.90). In stratified analysis (p < 0.001 for interaction of case volume by organ failure), mortality benefit associated with case volume was limited to patients with single organ dysfunction (n = 48,607, 34.3% of transfers) (odds ratio, 0.66; 95% CI, 0.55-0.80). Treatment at highest volume hospitals was significantly associated with shorter adjusted length of stay (incidence rate ratio, 0.86; 95% CI, 0.75-0.98) but not costs (% charge difference, 95% CI: [-]18.8, [-]37.9 to [+]0.3). CONCLUSIONS Hospital mortality was lowest among patients with severe sepsis who were transferred to high-volume hospitals; however, case volume benefits for transferred patients may be limited to patients with lower illness severity.
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Jeganathan N, Yau S, Ahuja N, Otu D, Stein B, Fogg L, Balk R. The characteristics and impact of source of infection on sepsis-related ICU outcomes. J Crit Care 2017; 41:170-176. [PMID: 28564621 DOI: 10.1016/j.jcrc.2017.05.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/02/2017] [Accepted: 05/20/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND Source of infection is an independent predictor of sepsis-related mortality. To date, studies have failed to evaluate differences in septic patients based on the source of infection. METHODS Retrospective study of all patients with sepsis admitted to the ICU of a university hospital within a 12month time period. RESULTS Sepsis due to intravascular device and multiple sources had the highest number of positive blood cultures and microbiology whereas lung and abdominal sepsis had the least. The observed hospital mortality was highest for sepsis due to multiple sources and unknown cause, and was lowest when due to abdominal, genitourinary (GU) or skin/soft tissue. Patients with sepsis due to lungs, unknown and multiple sources had the highest rates of multi-organ failure, whereas those with sepsis due to GU and skin/soft tissue had the lowest rates. Those with multisource sepsis had a significantly higher median ICU length of stay and hospital cost. CONCLUSION There are significant differences in patient characteristics, microbiology positivity, organs affected, mortality, length of stay and cost based on the source of sepsis. These differences should be considered in future studies to be able to deliver personalized care.
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Affiliation(s)
- Niranjan Jeganathan
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Stephen Yau
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Neha Ahuja
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Dara Otu
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Brian Stein
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Rush Medical College, Chicago, IL, USA
| | - Louis Fogg
- College of Nursing, Rush Medical College, Chicago, IL, USA
| | - Robert Balk
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Rush Medical College, Chicago, IL, USA
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Abstract
OBJECTIVE To evaluate the association between total medical contact, prehospital, and emergency department delays in antibiotic administration and in-hospital mortality among patient encounters with community-acquired sepsis. DESIGN Retrospective cohort study. SETTING Nine hospitals served by 21 emergency medical services agencies in southwestern Pennsylvania from 2010 through 2012. PATIENTS All emergency medical services encounters with community acquired sepsis transported to the hospital. MEASUREMENTS AND MAIN RESULTS Among 58,934 prehospital encounters, 2,683 had community-acquired sepsis, with an in-hospital mortality of 11%. Median time from first medical contact to antibiotic administration (total medical contact delay) was 4.2 hours (interquartile range, 2.7-8.0 hr), divided into a median prehospital delay of 0.52 hours (interquartile range, 0.40-0.66 hr) and a median emergency department delay of 3.6 hours (interquartile range, 2.1-7.5 hr). In a multivariable analysis controlling for other risk factors, total medical contact delay was associated with increased in-hospital mortality (adjusted odds ratio for death, 1.03 [95% CI, 1.00-1.05] per 1-hr delay; p < 0.01), as was emergency department delay (p = 0.04) but not prehospital delay (p = 0.61). CONCLUSIONS Both total medical contact and emergency department delay in antibiotic administration are associated with in-hospital mortality in community-acquired sepsis.
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Abstract
OBJECTIVE To describe the change in colposcopy volume in light of recent guideline shifts, which target higher-risk women while limiting unnecessary procedures in low-risk women. METHODS After institutional review board approval, colposcopy clinic visits at a large-volume referral center from January 2010 to December 2015 were reviewed. All women diagnosed with abnormal cervical cytology who were referred and subsequently underwent colposcopic evaluation were included. Mean monthly and annual clinic volumes were calculated. Return visit proportions were compared using chi-square test. Negative binomial regression analysis was used to examine trends. RESULTS There were a total of 8722 colposcopy clinic visits between January 2010 and December 2015. Approximately 7395 visits (85%) were new patient visits, and 1327 visits (15%) were return visits. The percentage of return visits declined dramatically during the study period from 22.9% (2011) of total visits to 9.0% in 2015 (P < 0.001). Annual clinic volume ranged from 903 to 1884 with a mean monthly volume of 121.13 visits (SD, 42.1). Annual volume was highest in 2011 (n = 1884) and has since demonstrated a steady decline. In 2015, average monthly volume (75.3 visits) dropped to nearly one third of its peak 218 visits per month in July 2010. CONCLUSIONS In a large referral clinic that adheres to guideline-based screening and management recommendations, monthly colposcopy volume has declined dramatically with a reduction by two thirds compared with peak volume in 2010.
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Wong GC, van Diepen S, Ainsworth C, Arora RC, Diodati JG, Liszkowski M, Love M, Overgaard C, Schnell G, Tanguay JF, Wells G, Le May M. Canadian Cardiovascular Society/Canadian Cardiovascular Critical Care Society/Canadian Association of Interventional Cardiology Position Statement on the Optimal Care of the Postarrest Patient. Can J Cardiol 2017; 33:1-16. [DOI: 10.1016/j.cjca.2016.10.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 02/07/2023] Open
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Arefian H, Heublein S, Scherag A, Brunkhorst FM, Younis MZ, Moerer O, Fischer D, Hartmann M. Hospital-related cost of sepsis: A systematic review. J Infect 2016; 74:107-117. [PMID: 27884733 DOI: 10.1016/j.jinf.2016.11.006] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This article systematically reviews research on the costs of sepsis and, as a secondary aim, evaluates the quality of economic evaluations reported in peer-reviewed journals. METHODS We systematically searched the MEDLINE, National Health Service (Abstracts of Reviews of Effects, Economic Evaluation and Health Technology Assessment), Cost-effectiveness Analysis Registry and Web of Knowledge databases for studies published between January 2005 and June 2015. We selected original articles that provided cost and cost-effectiveness analyses, defined sepsis and described their cost calculation method. Only studies that considered index admissions and re-admissions in the first 30 days were published in peer-reviewed journals and used standard treatments were considered. All costs were adjusted to 2014 US dollars. Medians and interquartile ranges (IQRs) for various costs of sepsis were calculated. The quality of economic studies was assessed using the Drummond 10-item checklist. RESULTS Overall, 37 studies met our eligibility criteria. The median of the mean hospital-wide cost of sepsis per patient was $32,421 (IQR $20,745-$40,835), and the median of the mean ICU cost of sepsis per patient was $27,461 (IQR $16,007-$31,251). Overall, the quality of economic studies was low. CONCLUSIONS Estimates of the hospital-related costs of sepsis varied considerably across the included studies depending on the method used for cost calculation, the type of sepsis and the population that was examined. A standard model for conducting cost improve the quality of studies on the costs of sepsis.
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Affiliation(s)
- Habibollah Arefian
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Hospital Pharmacy, Jena University Hospital, Jena, Germany.
| | - Steffen Heublein
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Hospital Pharmacy, Jena University Hospital, Jena, Germany
| | - André Scherag
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Research group Clinical Epidemiology, CSCC, Jena University Hospital, Jena, Germany
| | - Frank Martin Brunkhorst
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Center for Clinical Studies, Jena University Hospital, Jena, Germany; Paul-Martini-Clinical Sepsis Research Unit, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Mustafa Z Younis
- Health Policy and Management, Jackson State University, Jackson, MS, USA
| | - Onnen Moerer
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medicine, Georg-August-University, Goettingen, Germany
| | - Dagmar Fischer
- Department of Pharmaceutical Technology, Friedrich-Schiller University Jena, Germany
| | - Michael Hartmann
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany; Hospital Pharmacy, Jena University Hospital, Jena, Germany
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Validation of a Method to Identify Immunocompromised Patients with Severe Sepsis in Administrative Databases. Ann Am Thorac Soc 2016; 13:253-8. [PMID: 26650336 DOI: 10.1513/annalsats.201507-415bc] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
RATIONALE Immunocompromised patients are at high risk for developing severe sepsis. Currently, there are no validated strategies for identifying this group of patients in large administrative databases. OBJECTIVES We set out to define and validate a method that could be used to identify immunocompromised patients with severe sepsis in administrative databases. METHODS Patients were categorized as immunocompromised based on the presence of International Classification of Diseases, 9th revision discharge diagnosis codes and medication data. We validated this strategy by comparing the discriminatory ability of the search algorithm to that of manual chart review. MEASUREMENTS AND MAIN RESULTS We identified 4,438 patients at a single academic center with severe sepsis using a definition applied to administrative data described by Angus and colleagues. There were 1,185 (26.7%) who were categorized as immunocompromised based on our novel administrative data search strategy. Compared with identification by medical record review, the new administrative data search strategy had positive and negative predictive values of 94.4% (95% confidence interval [CI], 88.8-97.7%) and 94.3% (95% CI, 91.0-96.6%). The sensitivity and specificity were 87.4% (95% CI, 80.6-92.5%) and 97.6% (95% CI, 95.0-99.9%). CONCLUSIONS Patients who are immunosuppressed are a large subgroup of those with severe sepsis. Following its validation as a search strategy using other large databases, and its adaptation for International Classification of Diseases, 10th revision, this novel method may allow researchers to account for a patient's immune state when examining outcomes.
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Le May M, van Diepen S, Liszkowski M, Schnell G, Tanguay JF, Granger CB, Ainsworth C, Diodati JG, Fam N, Haichin R, Jassal D, Overgaard C, Tymchak W, Tyrrell B, Osborne C, Wong G. From Coronary Care Units to Cardiac Intensive Care Units: Recommendations for Organizational, Staffing, and Educational Transformation. Can J Cardiol 2016; 32:1204-1213. [DOI: 10.1016/j.cjca.2015.11.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/26/2015] [Accepted: 11/26/2015] [Indexed: 11/29/2022] Open
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Mehta AB, Douglas IS, Walkey AJ. Hospital Noninvasive Ventilation Case Volume and Outcomes of Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2016; 13:1752-1759. [PMID: 27404021 PMCID: PMC5122492 DOI: 10.1513/annalsats.201603-209oc] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
RATIONALE Higher hospital case volume may produce local expertise ("practice makes perfect"), resulting in better patient outcomes. Associations between hospital noninvasive ventilation (NIV) case volume and outcomes for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) are unclear. OBJECTIVES To determine associations between total hospital NIV case volume for all indications and NIV failure and hospital mortality among patients with acute exacerbations of COPD. METHODS Using the 2011 California State Inpatient Database and multivariable hierarchical logistic regression, we calculated hospital-level risk-adjusted rates for NIV failure (progression from NIV to invasive mechanical ventilation) and hospital mortality among patients with acute exacerbations of COPD. MEASUREMENTS AND MAIN RESULTS We identified 37,516 hospitalizations for acute exacerbations of COPD in 252 California hospitals in 2011. Total hospital NIV use for all indications ranged from 2 to 565 cases (median, 64; interquartile range, 96). Hospital NIV failure rates for acute exacerbations of COPD ranged from 3.7 to 31.3% (median, 8.5%; interquartile range, 4.2). At the hospital level, higher total hospital NIV case volume was weakly associated with higher hospital NIV failure rates for acute exacerbations of COPD (r = 0.13; P = 0.03). Higher hospital NIV failure rates were weakly associated with higher hospital mortality rates for acute exacerbations of COPD (r = 0.15; P = 0.02), but higher total hospital NIV case volume was not associated with hospital mortality for exacerbations of COPD (r = -0.11; P = 0.08). At the patient level, patients admitted to high-NIV versus low-NIV case-volume hospitals had greater odds of NIV failure (quartile 4 vs. quartile 1 adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.12-3.40). Compared with initial treatment with invasive mechanical ventilation, NIV failure was associated with higher odds of death (aOR, 1.81; 95% CI, 1.35-2.44). However, admission to high-NIV versus low-NIV case-volume hospitals was not significantly associated with patient in-hospital mortality (quartile 4 vs. quartile 1 aOR, 0.76; 95% CI, 0.57-1.02). CONCLUSIONS Despite strong evidence for use of NIV in the management of acute exacerbations of COPD, we observed no significant mortality benefit and higher rates of NIV failure in high-NIV case-volume hospitals. Further investigation of patient selection and hospital factors associated with NIV failure is needed to maximize favorable patient outcomes associated with use of NIV for acute exacerbations of COPD.
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Affiliation(s)
- Anuj B. Mehta
- The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, and
| | - Ivor S. Douglas
- Division of Pulmonary and Critical Care Medicine, Denver Health, Denver, Colorado; and
- Division of Pulmonary Sciences and Critical Care Medicine, School of Medicine, University of Colorado Anschutz Campus, Aurora, Colorado
| | - Allan J. Walkey
- The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, and
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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Kievlan DR, Martin-Gill C, Kahn JM, Callaway CW, Yealy DM, Angus DC, Seymour CW. External validation of a prehospital risk score for critical illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:255. [PMID: 27515164 PMCID: PMC5050704 DOI: 10.1186/s13054-016-1408-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/13/2016] [Indexed: 12/23/2022]
Abstract
Background Identification of critically ill patients during prehospital care could facilitate early treatment and aid in the regionalization of critical care. Tools to consistently identify those in the field with or at higher risk of developing critical illness do not exist. We sought to validate a prehospital critical illness risk score that uses objective clinical variables in a contemporary cohort of geographically and temporally distinct prehospital encounters. Methods We linked prehospital encounters at 21 emergency medical services (EMS) agencies to inpatient electronic health records at nine hospitals in southwestern Pennsylvania from 2010 to 2012. The primary outcome was critical illness during hospitalization, defined as an intensive care unit stay with delivery of organ support (mechanical ventilation or vasopressor use). We calculated the prehospital risk score using demographics and first vital signs from eligible EMS encounters, and we tested the association between score variables and critical illness using multivariable logistic regression. Discrimination was assessed using the AUROC curve, and calibration was determined by plotting observed versus expected events across score values. Operating characteristics were calculated at score thresholds. Results Among 42,550 nontrauma, non-cardiac arrest adult EMS patients, 1926 (4.5 %) developed critical illness during hospitalization. We observed moderate discrimination of the prehospital critical illness risk score (AUROC 0.73, 95 % CI 0.72–0.74) and adequate calibration based on observed versus expected plots. At a score threshold of 2, sensitivity was 0.63 (95 % CI 0.61–0.75), specificity was 0.73 (95 % CI 0.72–0.73), negative predictive value was 0.98 (95 % CI 0.98–0.98), and positive predictive value was 0.10 (95 % CI 0.09–0.10). The risk score performance was greater with alternative definitions of critical illness, including in-hospital mortality (AUROC 0.77, 95 % CI 0.7 –0.78). Conclusions In an external validation cohort, a prehospital risk score using objective clinical data had moderate discrimination for critical illness during hospitalization. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1408-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel R Kievlan
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall #607, Pittsburgh, PA, 15261, USA. .,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA.
| | | | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall #607, Pittsburgh, PA, 15261, USA.,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall #607, Pittsburgh, PA, 15261, USA.,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall #607, Pittsburgh, PA, 15261, USA.,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA.,Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Goodwin AJ, Nadig NR, McElligott JT, Simpson KN, Ford DW. Where You Live Matters: The Impact of Place of Residence on Severe Sepsis Incidence and Mortality. Chest 2016; 150:829-836. [PMID: 27445093 DOI: 10.1016/j.chest.2016.07.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 06/15/2016] [Accepted: 07/05/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Medically underserved areas are composed of vulnerable populations with reduced access to ambulatory care services. Our goal was to determine the association between residence in a medically underserved area and severe sepsis incidence and mortality. METHODS Using administrative data, we identified adults admitted with severe sepsis to nonfederal hospitals in South Carolina. We determined whether each resident lived in a medically underserved area or nonmedically underserved area from US Census and Department of Health and Human Services data. Age-adjusted severe sepsis incidence and mortality rates were calculated and compared between both residential classifications. Multivariate logistic regression measured the association between residence in a medically underserved area and mortality while adjusting for confounders. RESULTS In 2010, 24,395 adults were admitted with severe sepsis and 1,446,987 (43%) adults lived in a medically underserved area. Residents of medically underserved areas were admitted more frequently with severe sepsis (8.6 vs 6.8 cases/1,000 people, P < .01) and were more likely to die (15.5 vs 11.9 deaths/10,000 people, P < .01), with increased odds of severe sepsis-related death (OR, 1.12) after adjustment for age, race, and severity of illness. ZIP code-based surrogates of socioeconomic status, including median income, proportion below poverty level, and educational attainment, however, had minimal association with sepsis mortality. CONCLUSIONS Residence in a medically underserved area is associated with higher incidence and mortality rates of severe sepsis and represents a novel method of access-to-care adjustment. Traditional access-to-care surrogates, however, are poorly associated with sepsis mortality.
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Affiliation(s)
- Andrew J Goodwin
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC.
| | - Nandita R Nadig
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - James T McElligott
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Kit N Simpson
- Department of Health Care Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - Dee W Ford
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC
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Katz JN, Minder M, Olenchock B, Price S, Goldfarb M, Washam JB, Barnett CF, Newby LK, van Diepen S. The Genesis, Maturation, and Future of Critical Care Cardiology. J Am Coll Cardiol 2016; 68:67-79. [DOI: 10.1016/j.jacc.2016.04.036] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 12/29/2022]
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Abstract
Abstract
Background
The relationship between annualized case volume and mortality in patients with sepsis is not fully understood. The authors performed a dose–response meta-analysis to assess the effect of annualized case volume on mortality among patients with sepsis in the intensive care unit, emergency department, or hospital, hypothesizing that higher annualized case volume may lead to lower mortality.
Methods
The authors searched PubMed and Embase through July 2015 to identify observational studies that examined the relationship between annualized case volume and mortality in sepsis. The predefined outcome was mortality. Odds ratios with 95% CIs were pooled using a random-effects model.
Results
Ten studies involving 3,495,921 participants and 834,009 deaths were included. The pooled estimate suggested that annualized case volume was inversely associated with mortality (odds ratio, 0.76; 95% CI, 0.65 to 0.89; P = 0.001), with high heterogeneity (I2 = 96.6%). The relationship was consistent in most subgroup analyses and robust in sensitivity analysis. Dose–response analysis identified a nonlinear relationship between annualized case volume and mortality (P for nonlinearity less than 0.001).
Conclusions
This meta-analysis confirmed the study hypothesis and provided strong evidence for an inverse and a nonlinear dose–response relationship between annualized case volume and mortality in patients with sepsis. Variations in cutoff values of category for annualized case volume across studies may mainly result in the overall heterogeneity. Future studies should uncover the mechanism of volume–mortality relationship and standardize the cutoff values of category for annualized case volume in patients with sepsis.
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