1,027 research outputs found
Hospital Variation in Utilization of LifeâSustaining Treatments among Patients with Do Not Resuscitate Orders
Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/144225/1/hesr12651_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144225/2/hesr12651.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144225/3/hesr12651-sup-0001-AuthorMatrix.pd
HospitalâLevel Variation in the Use of Intensive Care
Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/93706/1/hesr1402.pd
Utilization of Intensive Care Unit Nutrition Consultation Is Associated With Reduced Mortality
BackgroundThe aim of this project was to investigate the prevalence of nutrition consultation (NC) in U.S. intensive care units (ICUs) and to examine its association with patient outcomes.MethodsData from the Healthcare Cost and Utilization Projectâs state inpatient databases was utilized from 2010 â 2014. A multilevel logistic regression model was used to evaluate the relationship between NC and clinical outcomes.ResultsInstitutional ICU NC rates varied significantly (mean: 14%, range: 0.1%â 73%). Significant variation among underlying disease processes was identified, with burn patients having the highest consult rate (P < 0.001, mean: 6%, range: 2%â 25%). ICU patients who received NC had significantly lower inâ hospital mortality (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.48â 0.74, P < 0.001), as did the subset with malnutrition (OR 0.72, 95% CI 0.53â 0.99, P = 0.047) and the subset with concomitant physical therapy consultation (OR 0.53, 95% CI 0.38â 0.74, P < 0.001). NC was associated with significantly lower rates of intubation, pulmonary failure, pneumonia, and gastrointestinal bleeding (P < 0.05). Furthermore, patients who received NC were more likely to receive enteral or parenteral nutrition (ENPN) (OR 1.8, 95% CI 1.4â 2.3, P < 0.001). Patients who received followâ up NC were even more likely to receive ENPN (OR 3.0, 95% CI 2.1â 4.2, P < 0.001).ConclusionsRates of NC were low in critically ill patients. This study suggests that increased utilization of NC in critically ill patients may be associated with improved clinical outcomes.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154413/1/jpen1534_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154413/2/jpen1534.pd
Prehospital Systolic Blood Pressure Thresholds: A Communityâbased Outcomes Study
Objectives Emergency medical services (EMS) personnel commonly use systolic blood pressure ( sBP ) to triage and treat acutely ill patients. The definition of prehospital hypotension and its associated outcomes are poorly defined. The authors sought to determine the discrimination of prehospital sBP thresholds for 30âday mortality and to compare patient classification by bestâperforming thresholds to traditional cutoffs. Methods In a communityâbased cohort of adult, nontrauma, noncardiac arrest patients transported by EMS between 2002 and 2006, entries to state hospital discharge data and death certificates were linked. Prehospital sBP thresholds between 40 and 140 mm Hg in derivation ( n =  132,624) and validation ( n =  22,020) cohorts and their discrimination for 30âday mortality, were examined. Cutoffs were evaluated using the 0/1 distance, Youden index, and adjusted Zâstatistics from multivariable logistic regression models. Results In the derivation cohort, 1,594 (1.2%) died within 24 hours, 7,404 (6%) were critically ill during hospitalization, and 6,888 (5%) died within 30 days. The area under the receiver operating characteristic (ROC) curve for sBP was 0.60 (95% confidence interval [CI] = 0.59, 0.61) for 30âday mortality and 0.64 (95% CI = 0.62 0.66) for 24âhour mortality. The 0/1 distance, Youden index, and adjusted Zâstatistics found bestâperforming sBP thresholds between 110 and 120 mm Hg. When compared to an sBP ⤠90 mm Hg, a cutoff of 110 mm Hg would identify 17% ( n =  137) more deaths at 30 days, while overtriaging four times as many survivors. Conclusions Prehospital sBP is a modest discriminator of clinical outcomes, yet no threshold avoids substantial misclassification of 30âday mortality among noninjured patients. Resumen Los Umbrales de la PresiĂłn Arterial SistĂłlica Prehospitalaria: Un Estudio de Base Comunitaria Acerca de la EvoluciĂłn de los Pacientes Objetivos El personal de los sistemas de emergencias mĂŠdicas ( SEM ) usa frecuentemente la presiĂłn arterial sistĂłlica ( PAS ) para clasificar y tratar a los pacientes agudos. Las definiciones de hipotensiĂłn prehospitalaria y sus resultados asociados estĂĄn pobremente definidos. Se determinĂł la discriminaciĂłn de los umbrales de PAS prehospitalaria para la mortalidad a los 30 dĂas, y se comparĂł la clasificaciĂłn del paciente por los mejores umbrales con los puntos de corte tradicionales. MetodologĂa Estudio de cohorte de base comunitaria de pacientes adultos no traumatolĂłgicos ni con paradas cardiorrespiratorias transportados por los SEM entre 2002 y 2006, cuyas historias estaban vinculadas con los datos de alta hospitalaria y los certificados de mortalidad. Se examinaron los umbrales de PAS prehospitalaria entre 40 mm Hg y 140 mm Hg en las cohortes de derivaciĂłn ( n =  132.624), y validaciĂłn ( n =  22,020), y su discriminaciĂłn para la mortalidad a los 30 dĂas. Los puntos de corte se evaluaron usando la distancia 0/1, el Ăndice de Youden y los estadĂsticos Z ajustados de los modelos de regresiĂłn logĂstica multivariable. Resultados: En la cohorte de derivaciĂłn, 1.594 (1,2%) fallecieron en las primeras 24 horas, 7.404 (6%) estuvieron crĂticamente enfermos durante el ingreso y 6.888 (5%) fallecieron en los 30 primeros dĂas. El ĂĄrea bajo la curva de la ROC para PAS fue 0,60 ( IC 95% = 0,59â0,61) para la mortalidad a los 30 dĂas y 0,64 ( IC 95% = 0,62â0,66) para la mortalidad a las 24 horas. La distancia 0/1, el Ăndice de Youden y las estadĂsticas Z ajustadas hallaronque los mejores umbrales de PAS estaban entre 110 y 120 mm Hg. Cuando se comparĂł con una PAS ⤠90 mm Hg, un punto de corte de 110 mm Hg identificarĂa un 17% ( n =  137) mĂĄs de muertes a los 30 dĂas, mientras que sobreclasificarĂa cuatro veces mĂĄs a los supervivientes. Conclusiones La presiĂłn arterial sistĂłlica es un discriminador modesto de resultados clĂnicos. No obstante, ningĂşn umbral evita una mala clasificaciĂłn de la mortalidad a los 30 dĂas entre los pacientes no traumatolĂłgicos.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/1/acem12142-sup-0002-DataSupplementS2_FigS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/2/acem12142-sup-0007-DataSupplementS7_FigS4.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/3/acem12142-sup-0006-DataSupplementS6_FigS3.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/4/acem12142-sup-0009-DataSupplementS9_TableS3.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/5/acem12142-sup-0003-DataSupplementS3.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/6/acem12142-sup-0008-DataSupplementS8_TableS2.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/7/acem12142-sup-0004-DataSupplementS4_TableS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/8/acem12142-sup-0001-DataSupplementS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/98303/9/acem12142.pd
SCAMP:standardised, concentrated, additional macronutrients, parenteral nutrition in very preterm infants: a phase IV randomised, controlled exploratory study of macronutrient intake, growth and other aspects of neonatal care
<p>Abstract</p> <p>Background</p> <p>Infants born <29 weeks gestation are at high risk of neurocognitive disability. Early postnatal growth failure, particularly head growth, is an important and potentially reversible risk factor for impaired neurodevelopmental outcome. Inadequate nutrition is a major factor in this postnatal growth failure, optimal protein and calorie (macronutrient) intakes are rarely achieved, especially in the first week. Infants <29 weeks are dependent on parenteral nutrition for the bulk of their nutrient needs for the first 2-3 weeks of life to allow gut adaptation to milk digestion. The prescription, formulation and administration of neonatal parenteral nutrition is critical to achieving optimal protein and calorie intake but has received little scientific evaluation. Current neonatal parenteral nutrition regimens often rely on individualised prescription to manage the labile, unpredictable biochemical and metabolic control characteristic of the early neonatal period. Individualised prescription frequently fails to translate into optimal macronutrient delivery. We have previously shown that a standardised, concentrated neonatal parenteral nutrition regimen can optimise macronutrient intake.</p> <p>Methods</p> <p>We propose a single centre, randomised controlled exploratory trial of two standardised, concentrated neonatal parenteral nutrition regimens comparing a standard macronutrient content (maximum protein 2.8 g/kg/day; lipid 2.8 g/kg/day, dextrose 10%) with a higher macronutrient content (maximum protein 3.8 g/kg/day; lipid 3.8 g/kg/day, dextrose 12%) over the first 28 days of life. 150 infants 24-28 completed weeks gestation and birthweight <1200 g will be recruited. The primary outcome will be head growth velocity in the first 28 days of life. Secondary outcomes will include a) auxological data between birth and 36 weeks corrected gestational age b) actual macronutrient intake in first 28 days c) biomarkers of biochemical and metabolic tolerance d) infection biomarkers and other intravascular line complications e) incidence of major complications of prematurity including mortality f) neurodevelopmental outcome at 2 years corrected gestational age</p> <p>Trial registration</p> <p>Current controlled trials: <a href="http://www.controlled-trials.com/ISRCTN76597892">ISRCTN76597892</a>; EudraCT Number: 2008-008899-14</p
Red blood cell transfusion and outcomes in patients with acute lung injury, sepsis and shock
Introduction: In this study, we sought to determine the association between red blood cell (RBC) transfusion and outcomes in patients with acute lung injury (ALI), sepsis and shock.Methods: We performed a secondary analysis of new-onset ALI patients enrolled in the Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment Trial (2000 to 2005) who had a documented ALI risk factor of sepsis or pneumonia and met shock criteria (mean arterial pressure (MAP) < 60 mmHg or vasopressor use) within 24 hours of randomization. Using multivariable logistic regression, we examined the association between RBC transfusion and 28-day mortality after adjustment for age, sex, race, randomization arm and Acute Physiology and Chronic Health Evaluation III score. Secondary end points included 90-day mortality and ventilator-free days (VFDs). Finally, we examined these end points among the subset of subjects meeting prespecified transfusion criteria defined by five simultaneous indicators: hemoglobin < 10.2 g/dL, central or mixed venous oxygen saturation < 70%, central venous pressure ⼠8 mmHg, MAP ⼠65 mmHg, and vasopressor use.Results: We identified 285 subjects with ALI, sepsis, shock and transfusion data. Of these, 85 also met the above prespecified transfusion criteria. Fifty-three (19%) of the two hundred eighty-five subjects with shock and twenty (24%) of the subset meeting the transfusion criteria received RBC transfusion within twenty-four hours of randomization. We found no independent association between RBC transfusion and 28-day mortality (odds ratio = 1.49, 95% CI (95% confidence interval) = 0.77 to 2.90; P = 0.23) or VFDs (mean difference = -0.35, 95% CI = -4.03 to 3.32; P = 0.85). Likewise, 90-day mortality and VFDs did not differ by transfusion status. Among the subset of patients meeting the transfusion criteria, we found no independent association between transfusion and mortality or VFDs.Conclusions: In patients with new-onset ALI, sepsis and shock, we found no independent association between RBC transfusion and mortality or VFDs. The physiological criteria did not identify patients more likely to be transfused or to benefit from transfusion. Š 2011 Parsons et al. licensee BioMed Central Ltd
Cost-effectiveness of Implementing Low-Tidal Volume Ventilation in Patients With Acute Lung Injury
Background: Despite widespread guidelines recommending the use of lung-protective ventilation (LPV) in patients with acute lung injury (ALI), many patients do not receive this lifesaving therapy. We sought to estimate the incremental clinical and economic outcomes associated with LPV and determined the maximum cost of a hypothetical intervention to improve adherence with LPV that remained cost-effective.
Methods: Adopting a societal perspective, we developed a theoretical decision model to determine the cost-effectiveness of LPV compared to non-LPV care. Model inputs were derived from the literature and a large population-based cohort of patients with ALI. Cost-effectiveness was determined as the cost per life saved and the cost per quality-adjusted life-years (QALYs) gained.
Results: Application of LPV resulted in an increase in QALYs gained by 15% (4.21 years for non-LPV vs 4.83 years for LPV), and an increase in lifetime costs of 99,588 for non-LPV vs 22,566 per life saved at hospital discharge and 9,482. Results were robust to a wide range of economic and patient parameter assumptions.
Conclusions: Even a costly intervention to improve adherence with low-tidal volume ventilation in patients with ALI reduces death and is cost-effective by current societal standards.NIH F32HL090220.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/84154/1/Cooke - CEA LPV.pd
Generating Operative Workflows for Vestibular Schwannoma Resection: A Two-Stage Delphi's Consensus in Collaboration with the British Skull Base Society. Part 2: The Translabyrinthine Approach
ObjectiveâAn operative workflow systematically compartmentalizes operations into hierarchal components of phases, steps, instrument, technique errors, and event errors. Operative workflow provides a foundation for education, training, and understanding of surgical variation. In this Part 2, we present a codified operative workflow for the translabyrinthine approach to vestibular schwannoma resection.
MethodsâA mixed-method consensus process of literature review, small-group Delphi's consensus, followed by a national Delphi's consensus was performed in collaboration with British Skull Base Society (BSBS). Each Delphi's round was repeated until data saturation and over 90% consensus was reached.
ResultsâSeventeen consultant skull base surgeons (nine neurosurgeons and eight ENT [ear, nose, and throat]) with median of 13.9 years of experience (interquartile range: 18.1 years) of independent practice participated. There was a 100% response rate across both the Delphi rounds. The translabyrinthine approach had the following five phases and 57 unique steps: Phase 1, approach and exposure; Phase 2, mastoidectomy; Phase 3, internal auditory canal and dural opening; Phase 4, tumor debulking and excision; and Phase 5, closure.
ConclusionâWe present Part 2 of a national, multicenter, consensus-derived, codified operative workflow for the translabyrinthine approach to vestibular schwannomas. The five phases contain the operative, steps, instruments, technique errors, and event errors. The codified translabyrinthine approach presented in this manuscript can serve as foundational research for future work, such as the application of artificial intelligence to vestibular schwannoma resection and comparative surgical research
The validity of using ICD-9 codes and pharmacy records to identify patients with chronic obstructive pulmonary disease
Background: Administrative data is often used to identify patients with chronic obstructive pulmonary disease (COPD), yet the validity of this approach is unclear. We sought to develop a predictive model utilizing administrative data to accurately identify patients with COPD.
Methods: Sequential logistic regression models were constructed using 9573 patients with postbronchodilator spirometry at two Veterans Affairs medical centers (2003-2007). COPD was defined as: 1) FEV1/FVC <0.70, and 2) FEV1/FVC < lower limits of normal. Model inputs included age, outpatient or inpatient COPD-related ICD-9 codes, and the number of metered does inhalers (MDI) prescribed over the one year prior to and one year post spirometry. Model performance was assessed using standard criteria.
Results: 4564 of 9573 patients (47.7%) had an FEV1/FVC < 0.70. The presence of âĽ1 outpatient COPD visit had a sensitivity of 76% and specificity of 67%; the AUC was 0.75 (95% CI 0.74-0.76). Adding the use of albuterol MDI increased the AUC of this model to 0.76 (95% CI 0.75-0.77) while the addition of ipratropium bromide MDI increased the AUC to 0.77 (95% CI 0.76-0.78). The best performing model included: âĽ6 albuterol MDI, âĽ3 ipratropium MDI, âĽ1 outpatient ICD-9 code, âĽ1 inpatient ICD-9 code, and age, achieving an AUC of 0.79 (95% CI 0.78-0.80).
Conclusion: Commonly used definitions of COPD in observational studies misclassify the majority of patients as having COPD. Using multiple diagnostic codes in combination with pharmacy data improves the ability to accurately identify patients with COPD.Department of Veterans Affairs, Health Services Research and Development (DHA), American Lung Association (CI- 51755-N) awarded to DHA, the American Thoracic Society Fellow Career Development AwardPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/84155/1/Cooke - ICD9 validity in COPD.pd
Social Influence in Televised Election Debates: A Potential Distortion of Democracy
A recent innovation in televised election debates is a continuous response measure (commonly referred to as the âwormâ) that allows viewers to track the response of a sample of undecided voters in real-time. A potential danger of presenting such data is that it may prevent people from making independent evaluations. We report an experiment with 150 participants in which we manipulated the worm and superimposed it on a live broadcast of a UK election debate. The majority of viewers were unaware that the worm had been manipulated, and yet we were able to influence their perception of who won the debate, their choice of preferred prime minister, and their voting intentions. We argue that there is an urgent need to reconsider the simultaneous broadcast of average response data with televised election debates
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