Can Tracheostomy Improve Outcome and Lower Resource Utilization for Patients with Prolonged Mechanical Ventilation?

Background: It is not clear whether the benefits of tracheostomy remain the same in the population. This study aimed to better examine the effect of tracheostomy on clinical outcome among prolonged ventilator patients. Methods: Data were from the medical claims data in Taiwan. A total of 3880 patients with ventilator use for more than 14 days between 2005 and 2009 were identified. Among them, 645 patients with tracheostomy conducted within 30 days of ventilator use were compared to 2715 patients without tracheostomy on death during hospitalization and study period, and successful weaning and medical utilization during hospitalization. Cox proportional hazards and linear regression models were used to examine the associations between tracheostomy and the main outcomes. Results: The tracheostomy rate was 30%, and 55% of tracheostomies were performed within 30 days of mechanical ventilation. After adjustments, patients with tracheostomy were at a lower risk of death during hospitalization (hazard ratio [HR] =0.51; 95% confidence interval [CI] =0.43–0.61) and 5-year observation (HR = 0.73; 95% CI = 0.66–0.81), and a lower probability of successful weaning (HR = 0.88; 95% CI = 0.79–0.99). Higher medical use was also observed in patients with tracheostomy. Conclusions: The beneficial effect for tracheostomy observed in our data was the reduction of death. However, patients with tracheostomy were less likely to wean and more likely to consume medical resources

Impact of Urinary Catheterization on Geriatric Inpatients with Community-acquired Urinary Tract Infections

Urinary tract infections commonly cause hospitalizations in community-dwelling geriatric populations. Our aim was to understand the impact of urinary catheterization on geriatric inpatients with community-acquired urinary tract infections (CAUTIs). Methods: Retrospective analyses were performed using electronic discharge summaries in a rural community hospital of northeastern Taiwan in 2004. We screened data with ICD-9-CM codes and performed chart reviews on inpatients aged ≥65 years with CAUTIs. Results: A total of 294 subjects who experienced CAUTIs were enrolled; 114 subjects had urinary catheterization and the other 180 did not. The mean frequency of admission was 1.2 times (range, 1-4 times); 251 subjects were admitted only once. We reviewed and enrolled 348 records of CAUTIs. Subjects with urinary catheterization showed significantly more advanced age, more female predominance, higher immobility ratio, and more frequent admissions than those without urinary catheterization (p<0.05). Records of urinary catheterization showed that subjects had longer hospital stays, higher pathogen isolation after culture, and less comorbid pyelonephritis than subjects without urinary catheterization (p<0.05). The distribution of infecting microorganisms differed insignificantly between the 2 groups (p = 0.077). Female gender, hospitalization > 2 times, age ≥75 years, immobility, hospital stay > 7 days, and low prevalence of comorbid pyelonephritis served as significant predictive variables for urinary catheterization in subjects with CAUTIs. Conclusion: For geriatric inpatients, urinary catheterization must be evaluated cautiously before being performed. The impact of urinary catheterization on the distribution of microorganisms in CAUTIs was shown to be insignificant

The Impact of Nationwide Education Program on Clinical Practice in Sepsis Care and Mortality of Severe Sepsis: A Population-Based Study in Taiwan

<div><p>Objectives</p><p>We investigated the effect of a nationwide educational program following surviving sepsis campaign (SSC) guidelines. Physicians’ clinical practice in sepsis care and patient mortality rate for severe sepsis were analyzed using a nationally representative cohort.</p> <p>Methods</p><p>Hospitalizations for severe sepsis with organ failure from 1997 to 2008 were extracted from Taiwan’s National Health Insurance Research Database (NHIRD), and trends in sepsis incidence and mortality rates were analyzed. A before-and-after study design was used to evaluate changes in the utilization rates of SSC items and changes in severe sepsis mortality rates occurred after a national education program conducted by the Joint Taiwan Critical Care Medicine Committee since 2004. A total of 39,706 hospitalizations were analyzed, which consisted of a pre-intervention cohort of 14,848 individuals (2000-2003) and a post-intervention cohort of 24,858 individuals (2005-2008).</p> <p>Results</p><p>The incidence rate of severe sepsis increased from 1.88 per 1,000 individuals in 1997 to 5.07 per 1,000 individuals in 2008. The cumulative mortality rate decreased slightly from 48.2% for the pre-intervention cohort to 45.9% for the post-intervention cohort. The utilization rates of almost all SSC items changed significantly between the pre-intervention and post-intervention cohorts. These changes of utilization rates were found to be associated with mild reduction in mortality rate.</p> <p>Conclusion</p><p>The nationwide education program through a national professional society has a significant impact on physicians’ clinical practice and resulted in a slight but significant reduction of severe sepsis mortality rate.</p> </div

Administrative and Claims Data Help Predict Patient Mortality in Intensive Care Units by Logistic Regression: A Nationwide Database Study

Background. Increasing attention has been paid to the predictive power of different prognostic scoring systems for decades. In this study, we compared the abilities of three commonly used scoring systems to predict short-term and long-term mortalities, with the intention of building a better prediction model for critically ill patients. We used the data from the National Health Insurance Research Database (NHIRD) in Taiwan, which included information on patient age, comorbidities, and presence of organ failure to build a new prediction model for short-term and long-term mortalities. Methods. We retrospectively collected the medical records of patients in the intensive care unit of a regional hospital in 2012 and linked them to the claims data from the NHIRD. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Elixhauser Comorbidity Index (ECI), and Charlson Comorbidity Index (CCI) were compared for their predictive abilities. Multiple logistic regression tests were performed, and the results were presented as receiver operating characteristic curves and C-statistic. Results. The APACHE II score has the best predictive power for inhospital mortality (0.79; C−statistic=0.77−0.83) and 1-year mortality (0.77; C−statistic=0.74−0.79). The ECI and CCI alone have poorer predictive power and need to be combined with other variables to be comparable to the APACHE II score, as predictive tools. Using CCI together with age, sex, and whether or not the patient required mechanical ventilation is estimated to have a C-statistic of 0.773 (95% CI 0.744-0.803) for inhospital mortality, 0.782 (95% CI 0.76-0.81) for 30-day mortality, and 0.78 (95% CI 0.75-0.80) for 1-year mortality. Conclusions. We present a new prognostic model that combines CCI with age, sex, and mechanical ventilation status and can predict mortality, comparable to the APACHE II score

Annual incidence rates and observed mortality rates for hospitalizations with severe sepsis with organ failure between 1997 and 2008 in Taiwan.

<p>(The nationwide SSC program was launched in 2004.)</p

Effects of utilization rate changes for items in the SSC guidelines on changes in mortality rates in Taiwan (pre-intervention cohort (2000-2003, before SSC program) vs. post-intervention cohort (2005-2008, after SSC program), n=39,706).

<p>Effects of utilization rate changes for items in the SSC guidelines on changes in mortality rates in Taiwan (pre-intervention cohort (2000-2003, before SSC program) vs. post-intervention cohort (2005-2008, after SSC program), n=39,706).</p

Utilization rate changes for items in the SSC guidelines before and after the SSC program was implemented in Taiwan.

<p>(pre-intervention cohort (2000-2003, before SSC program) vs. post-intervention cohort (2005-2008, after SSC program), n=39,706).</p

Readmission to the intensive care unit: A population-based approach

Readmission to the intensive care unit (ICU) results in increased consumption of medical resources and costs, and has been proposed as a marker for quality of care. ICU readmission rates have been estimated at 4–14% and different risk factors have been proposed by various studies. Methods: Every admission event to the ICU was recorded and readmission episodes were analyzed using a population-based database from the Taiwan National Health Insurance Research Database (NHIRD) for the period from January 1, 2006 to December 31, 2006. Results: The average follow-up time was 206.35 days. From the database of 192,201 patients admitted to the ICU, 25,263 patients were re-admitted, with a readmission rate of 13.13%. The leading etiologies for readmission were identified. Using multivariate analysis, age > 39 years old, female gender, ischemic heart disease, lung related disorders, pneumonia, cerebrovascular disease, sepsis, heart failure, chronic liver disease, diabetes mellitus, and chronic obstructive pulmonary disease were identified as significant risk factors for readmission to the ICU. Conclusion: This study uses a novel approach to assess risk factors for readmission to the ICU. Higher risk patients should be assessed more carefully before discharge or transfer from the ICU to prevent readmission episodes

Health Effects of Medical Radiation on Cardiologists Who Perform Cardiac Catheterization

We investigated the health effects of low-dose radiation on cardiologists exposed to scattered radiation while performing cardiac catheterization (CC) in a hospital setting from 2003 to 2006. Methods: We performed a 4-year retrospective study on 2, 292 medical doctors, using claims data from all contracted hospitals of the Bureau of National Health Insurance, Taiwan. We gathered statistical data regarding radiation-related diseases using the International Classification of Diseases, 9th Revision, Clinical Modification record numbers of each doctor. Results: Of the 2,292 doctors evaluated, 1,721 were aged 35–50 years and the remaining 571 were aged 51–65 years. There were 892 cardiologists who performed CC (experimental group), and the majority of these (733/892, 82.17%) were aged 35–50 years. There were 1,400 medical doctors who performed no CC from 2003 to 2006 (control group). A total of 988 of these belonged to the 35–50 years age group and 412 to the 51–65 years group. In the 35–50 years group, the controls had significantly more medical visits for hematological and thyroid cancer (p <0.05), skin disease (p <0.001), and acute upper respiratory tract infection (p <0.001) compared with the experimental group. In contrast, cardiologists who performed catheterization had more cataracts compared with the control group, but this difference was not significant. Conclusion: Doctors who did not perform CC had more visits for radiation-related diseases than those who performed catheterization. In the experimental group, cardiologists aged 35–50 years who were exposed to radiation during CC had more visits for cataracts than the control group. We recommend that radiation protection concepts be emphasized to cardiologists, and that hospital managers be obligated to upgrade angiography equipment because the newer models have less scattered radiation