Using existing data to address important clinical questions in critical care

Objective: With important technological advances in healthcare delivery and the internet, clinicians and scientists now have access to overwhelming number of available databases capturing patients with critical illness. Yet investigators seeking to answer important clinical or research questions with existing data have few resources that adequately describe the available sources and the strengths and limitations of each. This article reviews an approach to selecting a database to address health services and outcomes research questions in critical care, examines several databases that are commonly used for this purpose, and briefly describes some strengths and limitations of each. Data Sources: Narrative review of the medical literature. Summary: The available databases that collect information on critically ill patients are numerous and vary in the types of questions they can optimally answer. Selection of a data source must not only consider accessibility, but also the quality of the data contained within the database, and the extent to which it captures the necessary variables for the research question. Questions seeking causal associations (e.g. effect of treatment on mortality) usually either require secondary data that contain detailed information about demographics, laboratories, and physiology to best address non-random selection or sophisticated study design. Purely descriptive questions (e.g. incidence of respiratory failure) can often be addressed using secondary data with less detail such as administrative claims. Though each database has its own inherent limitations, all secondary analyses will be subject to the same challenges of appropriate study design and good observational research. Conclusion: The literature demonstrates that secondary analyses can have significant impact on critical care practice. While selection of the optimal database for a particular question is a necessary part of high-quality analyses, it is not sufficient to guarantee an unbiased study. Thoughtful and well-constructed study design and analysis approaches remain equally important pillars of robust science. Only through responsible use of existing data will investigators ensure that their study has the greatest impact on critical care practice and outcomes.AHRQ K08 HS020672, NIH K08 HL091249Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106051/1/Cooke - Existing data in critical care.pd

Child Injury Risks are Close to Home: Parent Psychosocial Factors Associated with Child Safety

Objective: In several populations, maternal depression has been associated with reduced child safety. In an urban pediatric Emergency Department, we examined the relationship between parental depression, social support, and domestic conflict and child safety behaviors. Methods: We studied consecutive patients in an Emergency Department. Trained interviewers used a structured instrument to assess patient, primary caregiver, and household demographics, socio-economic status, psychosocial factors, child safety behaviors (whether a gun was in the home, poisons were locked, a functioning smoke detector was present, and use of carseats or seatbelts), and whether the home was smoke-free. 1,116 patients provided adequate data. Results: Depression was associated with a modest and not statistically significant reduction in child safety behaviors in this population. Lack of social support and the presence of domestic conflict were robustly, independently, and statistically significantly associated with less safe homes. Domestic conflict was associated with more smoking in the home. Conclusion: In our population, child safety was associated less with depression and more with parental lack of social support and domestic conflict. These can be assessed in a Emergency Department and may be amenable to intervention

Critical care use during the course of serious illness.

Despite its expense and importance, it is unknown how common critical care use is. We describe longitudinal patterns of critical care use among a nationally representative cohort of elderly patients monitored from the onset of common serious illnesses. A retrospective population-based cohort study of elderly patients in fee-for-service Medicare is used, with 1,108,060 Medicare beneficiaries at least 68 years of age and newly diagnosed with serious illnesses: 1 of 9 malignancies, stroke, congestive heart failure, hip fracture, or myocardial infarction. Medicare inpatient hospital claims from diagnosis until death (65.1%) or fixed-right censoring (more than 4 years) were reviewed. Distinct hospitalizations involving critical care use (intensive care unit or critical care unit) were counted and associated reimbursements were assessed; repeated use was defined as five or more such hospitalizations. Of the cohort, 54.9% used critical care at some time after diagnosis. Older patients were much less likely to ever use critical care (odds ratio, 0.31; comparing patients more than 90 years old with those 68-70 years old), even after adjustment. A total of 31,348 patients (2.8%) were repeated users of critical care; they accounted for 3.6 billion dollars in hospital charges and 1.4 billion dollars in Medicare reimbursement. We conclude that critical care use is common in serious chronic illness and is not associated solely with preterminal hospitalizations. Use is uneven, and a minority of patients who repeatedly use critical care account for disproportionate costs.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/61412/2/04.AJRCCM.supp.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61412/1/04.AJRCCM.pd

In Sickness and In Health: Understanding the Effects of Marriage on Health

My DissertationDespite substantial research, how marriage reduces mortality remains unclear. Using a novel data set of over 150,000 elderly couples developed from the Medicare claims and examining the impact of widowhood vs. marriage on mortality, this dissertation seeks to adjudicate among the many plausible mechanisms. First, I exploit the variation between diseases in how responsive those diseases are to putative intervening processes to test which hypotheses can explain patterns of relative mortality. I find that in general the less healthy a person is, the less responsive they are to the death of a spouse – the most enduring mortality effects of spousal death are found among the healthiest elderly. Thus, support is found for models in which marriage provides immediate instrumental help; marriage does not appear to improve health by improving habits or by increasing some other stock of health capital that inheres in patients after the death of their spouse. The major mortality benefits of marriage also are not mediated via direct emotional or physiological effects, nor are they an artifact of selection or shared environment. Second, I show that the married appear to choose better inpatient hospital care, as measured in a number of different ways. They then have longer lengths of stay than the widowed, but do not appear to receive differential quality of care given the provider chosen. In a final chapter, I argue that relationships improve health by serving as a form of general capital, most useful when individuals face a wide variety of choices about their health.National Research Service Award Grant 5 T32 GM07281 Population Research Center has also provided me with support as a predoctoral fellow, through National Research Service Award Grant T32-AG00243http://deepblue.lib.umich.edu/bitstream/2027.42/61424/27/Chapter_1_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/26/Chapter_2_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/25/Chapter_3_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/24/Chapter_4_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/23/Chapter_5_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/22/Appendix_A_with_Figures.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/21/Original_Appendices_B_and_C.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/10/Bibliography.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/61424/28/Front_Matter.pd

Survivorship Will Be the Defining Challenge of Critical Care in the 21st Century

In an invited editorial, I argue that critical care is facing a cross-roads. We can now save many patients lives. But we need to broaden our sense of our mission to include understanding, caring for, and improving, the lives of those many patients who survive critical illnessGrant Support: By the National Institutes of Health (grant K08HL091249).http://deepblue.lib.umich.edu/bitstream/2027.42/77540/1/10.Annals.Survivorship.Editorial.pd

The network structure of critical care transfers, 1993

Poster presented at Annual MeetingBackground: In light of wide variations between hospitals in their quality of critical care, some have proposed moving patients to better quality. A system of critical care transfers already exists, but it is little studied. Methods: All 1993 Medicare claims were examined for the 576 acute care hospitals in the Mid-Atlantic region. Results: Critical care transfers are common. There is a single continuous transfer network linking hospitals in the Mid-Atlantic region. There are signs that congestion may be a problem in this network. Conclusion: The existing transfer network may be a useful policy tool to improve the outcomes of critically ill patients, but more study is needed.NIH grant HL07891-09http://deepblue.lib.umich.edu/bitstream/2027.42/61403/1/SCCM_poster_comp.pd

Seduction and Insight from Cross-National Comparisons

Editorial discussing the stregnths and limitations of crossnational comparisons of critical care, with particular reference to Use of Intensive Care Services during Terminal Hospitalizations in England and the United States Hannah Wunsch, Walter T. Linde-Zwirble, David A. Harrison, Amber E. Barnato, Kathryn M. Rowan, and Derek C. Angus AJRCCM 2009 180: 875-880.Supported in part by 1K08HL091249-01 from the NIH/NHLBIhttp://deepblue.lib.umich.edu/bitstream/2027.42/64267/1/09.AJRCCM.editorial.seduction.insight.pd

Male Perpetrators of Intimate Partner Violence: Support for Health Care Interventions Targeted at Level of Risk

The mental health correlates of male aggression or violence against an intimate partner (IPV) are examined using exploratory cluster analysis for 81 men who self-reported risk factors for IPV perpetration on a computer-based health risk assessment. Men disclosing IPV perpetration could be meaningfully subdivided into two different clusters: a high pathology/high violence cluster, and lower pathology/low violence cluster. These groups appear to perpetrate intimate partner violence in differing psychoemotional contexts and could be robustly identified using multiple distinct analytic methods. If men who self-disclose IPV in a health care setting can be meaningfully subdivided based on mental health symptoms and level of violence, it lends support for potential new targeted approaches to preventing partner violence perpetration by both women and men.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65004/1/10.Rhodes.I.Behaviour.Change.pd

Marriage, widowhood, and health-care use

Despite suggestive evidence, there has been no adequately powered systematic study of the ways in which marital status influences health care consumption. Using a novel data set of 609016 newly diagnosed, seriously ill elderly individuals in the USA, and employing hierarchical linear models, we look at differences in the experience of hospitalization as a function of marital status. We find that the married consistently use higher quality hospitals and have shorter lengths of stay. On the other hand, the married and the widowed appear to receive similar quality care once they are in the hospital. Marital status thus has a substantial impact on the health care obtained by the elderly. We suggest that these patterns are most consistent with spouses exerting their benefits by functioning as higher-order decision-makers than as home health assistants.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/61411/1/03.I.Christakis.SSM.pd

Safety of extubating mechanically ventilated patients on vasoactive infusions: a retrospective cohort study

No abstract available