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Kopanczyk R, Lisco SJ, Pearl R, Demiralp G, Naik BI, Mazzeffi MA. Racial and Ethnic Disparities in Veno-Venous Extracorporeal Membrane Oxygenation Mortality for Patients With Severe COVID-19. ASAIO J 2024; 70:62-67. [PMID: 37815999 DOI: 10.1097/mat.0000000000002072] [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: 10/12/2023] Open
Abstract
Racial/ethnic disparities in mortality were observed during the coronavirus disease-2019 pandemic, but investigations examining the association between race/ethnicity and mortality during extracorporeal membrane oxygenation (ECMO) are limited. We performed a retrospective observational cohort study using the 2020 national inpatient sample. Multivariable logistic regression was used to estimate the odds of mortality in patients of difference race/ethnicity while controlling for confounders. There was a significant association between race/ethnicity and in-hospital mortality ( p < 0.001). Hispanic patients had significantly higher in-hospital mortality compared with White patients (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.16-1.67, p < 0.001). Black patients and patients of other races did not have significantly higher in-hospital mortality compared with White patients (OR = 0.82, 95% CI = 0.66-1.02, p = 0.07 and OR = 1.20, 95% CI = 0.92-1.57, p = 0.18). Other variables that had a significant association with mortality included age, insurance type, Charlson comorbidity index, all patient-refined severity of illness, and receipt of care in a low-volume ECMO center (all p < 0.001). Further studies are needed to understand causes of disparities in ECMO mortality.
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Affiliation(s)
- Rafal Kopanczyk
- From the Division of Critical Care, Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Steven J Lisco
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ronald Pearl
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, California
| | - Gozde Demiralp
- Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
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Lewis A. International variability in the diagnosis and management of disorders of consciousness. Presse Med 2023; 52:104162. [PMID: 36564000 DOI: 10.1016/j.lpm.2022.104162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/31/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
This manuscript explores the international variability in the diagnosis and management of disorders of consciousness (DoC). The identification, evaluation, intervention, exploration, prognostication and limitation of therapy for patients with DoC is reviewed through an international lens. The myriad factors that impact the diagnosis and management of DoC including 1) financial, 2) legal and regulatory, 3) cultural, 4) religious and 5) psychosocial considerations are discussed. As data comparing patients with DoC internationally are limited, findings from the general critical care or neurocritical care literature are described when information specific to patients with DoC is unavailable. There is a need for improvements in clinical care, education, advocacy and research related to patients with DoC worldwide. It is imperative to standardize methodology to evaluate consciousness and prognosticate outcome. Further, education is needed to 1) generate awareness of the impact of the aforementioned considerations on patients with DoC and 2) develop techniques to optimize communication about DoC with families. It is necessary to promote equity in access to expertise and resources for patients with DoC to enhance the care of patients with DoC worldwide. Improving understanding and management of patients with DoC requires harmonization of existing datasets, development of registries where none exist and establishment of international clinical trial networks that include patients in all phases along the spectrum of care. The work of international organizations like the Curing Coma Campaign can hopefully minimize international variability in the diagnosis and management of DoC and optimize care.
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Affiliation(s)
- Ariane Lewis
- Departments of Neurology and Neurosurgery, NYU Langone Medical Center, New York, NY, United States.
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Haines L, Wang W, Harhay M, Martin N, Halpern S, Courtright K. Opportunities to Improve Palliative Care Delivery in Trauma Critical Illness. Am J Hosp Palliat Care 2021; 39:633-640. [PMID: 34467775 DOI: 10.1177/10499091211042303] [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: 11/15/2022] Open
Abstract
BACKGROUND Despite recommendations to integrate palliative care (PC) into care for critically ill trauma patients, little is known about current PC practices in trauma care to inform opportunities for improvement. OBJECTIVE Describe patterns of PC delivery among a large, critically ill trauma cohort. SETTING/SUBJECTS Retrospective cohort study of adult (≥18 years) trauma patients admitted to an intensive care unit (ICU) at an urban, level one trauma center in the United States from March 1, 2017 to March 1, 2019. METHODS We linked the electronic medical record with the institutional trauma registry. PC process measures included a PC consult order, advance care planning (ACP) note, and hospice use. Unadjusted results are reported for the total population, decedents, and subgroups at risk for poor outcomes (age ≥55 years, Black race ≥1 pre-existing comorbidity, and severe injury) after trauma. RESULTS Among 1309 eligible admissions, 902 (68.9%) were male, 640 (48.9%) were Black, and 654 (50.0%) were ≥55 years old. Eighty-one (6.2%) patients received a PC consult order, 66 (5.0%) had an ACP note, and 13 (1.1%) were discharged to hospice. Among decedents (N = 91; 7%), 28 (30.8%) received a PC consult order and 36 (39.6%) had an ACP note. For high-risk subgroups, PC consult orders and ACP note rates ranged from 4.5-12.8% and 4.5-11.8%, respectively. CONCLUSION PC delivery was rare among this cohort, including those at high risk for poor outcomes. Urgent efforts are needed to identify barriers to and develop targeted interventions for high quality PC delivery in trauma ICU care.
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Affiliation(s)
- Lindsay Haines
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Wei Wang
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Michael Harhay
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Niels Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott Halpern
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Katherine Courtright
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
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Carlson JM, Etchill EW, Enriquez CAG, Peeler A, Whitman GJ, Choi CW, Geocadin RG, Cho SM. Population Characteristics and Markers for Withdrawal of Life-Sustaining Therapy in Patients on Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 36:833-839. [PMID: 34088552 DOI: 10.1053/j.jvca.2021.04.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/20/2021] [Accepted: 04/24/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE As survival with extracorporeal membrane oxygenation (ECMO) therapy improves, it is important to study patients who do not survive secondary to withdrawal of life-sustaining therapy (WLST). The purpose of the present study was to determine the population and clinical characteristics of those who experienced short latency to WLST. DESIGN Retrospective cohort study. SETTING Single academic hospital center. PARTICIPANTS Adult ECMO patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, 150 patients (mean age 54.8 ± 15.9 y, 43.3% female) underwent ECMO (80% venoarterial ECMO and 20% venovenous ECMO). Seventy-three (48.7%) had WLST from ECMO support (median five days), and 33 of those (45.2%) had early WLST (≤five days). Patients who underwent WLST were older (60.3 ± 15.3 y v 49.6 ± 14.7 y; p < 0.001) than those who did not undergo WLST and had greater body mass index (31.7 ± 7.6 kg/m2v 28.3 ± 5.5 kg/m2; p = 0.002), longer ECMO duration (six v four days; p = 0.01), and higher Acute Physiology and Chronic Health Evaluation (25 v 21; p < 0.001) and Sequential Organ Failure Assessment (12 v 11; p = 0.037) scores. Family request frequently (91.7%) was cited as part of the WLST decision. WLST patients experienced more chaplaincy (89% v 65%; p < 0.001), palliative care consults (53.4% v 29.9%; p = 0.003), and code status change (do not resuscitate: 83.6% v 7.8%; p < 0.001). CONCLUSIONS Nearly 50% of ECMO patients underwent WLST, with approximately 25% occurring in the first 72 hours. These patients were older, sicker, and experienced a different clinical context. Unlike with other critical illnesses, neurologic injury was not a primary reason for WLST in ECMO patients.
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Affiliation(s)
- Julia M Carlson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric W Etchill
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Clare Angeli G Enriquez
- Department of Neurosciences, University of the Philippines Manila-Philippine General Hospital, Manila, Philippines
| | - Anna Peeler
- Johns Hopkins University School of Nursing, Baltimore, MD
| | - Glenn J Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chun Woo Choi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko G Geocadin
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
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Slain KN, Barda A, Pronovost PJ, Thornton JD. Social Factors Predictive of Intensive Care Utilization in Technology-Dependent Children, a Retrospective Multicenter Cohort Study. Front Pediatr 2021; 9:721353. [PMID: 34589454 PMCID: PMC8475907 DOI: 10.3389/fped.2021.721353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/18/2021] [Indexed: 11/29/2022] Open
Abstract
Objective: Technology-dependent children with medical complexity (CMC) are frequently admitted to the pediatric intensive care unit (PICU). The social risk factors for high PICU utilization in these children are not well described. The objective of this study was to describe the relationship between race, ethnicity, insurance status, estimated household income, and PICU admission following the placement of a tracheostomy and/or gastrostomy (GT) in CMC. Study Design: This was a retrospective multicenter study of children <19 years requiring tracheostomy and/or GT placement discharged from a hospital contributing to the Pediatric Health Information System (PHIS) database between January 2016 and March 2019. Primary predictors included estimated household income, insurance status, and race/ethnicity. Additional predictor variables collected included patient age, sex, number of chronic complex conditions (CCC), history of prematurity, and discharge disposition following index hospitalization. The primary outcome was need for PICU readmission within 30 days of hospital discharge. Secondary outcomes included repeated PICU admissions and total hospital costs within 1 year of tracheostomy and/or GT placement. Results: Patients requiring a PICU readmission within 30 days of index hospitalization for tracheostomy or GT placement accounted for 6% of the 20,085 included subjects. In multivariate analyses, public insurance [OR 1.28 (95% C.I. 1.12-1.47), p < 0.001] was associated with PICU readmission within 30 days of hospital discharge while living below the federal poverty threshold (FPT) was associated with a lower odds of 30-day PICU readmission [OR 0.7 (95% C.I. 0.51-0.95), p = 0.0267]. Over 20% (n = 4,197) of children required multiple (>1) PICU admissions within one year from index hospitalization. In multivariate analysis, Black children [OR 1.20 (95% C.I. 1.10-1.32), p < 0.001] and those with public insurance [OR 1.34 (95% C.I. 1.24-1.46), p < 0.001] had higher odds of multiple PICU admissions. Social risk factors were not associated with total hospital costs accrued within 1 year of tracheostomy and/or GT placement. Conclusions: In a multicenter cohort study, Black children and those with public insurance had higher PICU utilization following tracheostomy and/or GT placement. Future research should target improving healthcare outcomes in these high-risk populations.
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Affiliation(s)
- Katherine N Slain
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, United States.,Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Amie Barda
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, United States
| | - Peter J Pronovost
- Case Western Reserve University School of Medicine, Cleveland, OH, United States.,Department of Anesthesiology and Critical Care Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - J Daryl Thornton
- Case Western Reserve University School of Medicine, Cleveland, OH, United States.,Center for Reducing Health Disparities, MetroHealth Campus of Case Western Reserve University, Cleveland, OH, United States.,Center for Population Health Research, MetroHealth Campus of Case Western Reserve University, Cleveland, OH, United States
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